15-year experience of laparoscopic gastrectomy in advanced gastric cancer: analysis on short-term and long-term oncologic outcome.

BACKGROUND: Laparoscopic gastrectomy (LG) is now a widely accepted treatment option for gastric cancer. However, there is insufficient evidence for LG for advanced gastric cancer (AGC). Many retrospective studies have shown that LG for AGC is safe and feasible, but very few studies have shown the actual outcome in general practice. The aim of this study is to analyze our last 15 years of experience in LG for AGC. METHODS: This is a retrospective review from May 2003 to May 2017 in Seoul National University Bundang Hospital. A total of 1592 patients who had LG for AGC were enrolled of which 109 patients with open conversion were excluded. We evaluated the short-term and long-term oncologic outcomes of LG for AGC. RESULTS: A total of 1483 patients were analyzed. There were 432 cases of total gastrectomy, 982 cases of distal gastrectomy, and 69 cases of proximal gastrectomy. The total complication rate was 9.1% (135/1483), which included wound-related complications (0.7%), postoperative bleeding (0.5%), anastomosis or stump leakage (2.2%), intestinal obstruction (0.9%), pancreatic fistula (0.1%), intra-abdominal abscess (1.6%), and lung morbidity (3.0%). The rate of Clavien-Dindo grade 3 and above complications was 4.9%. Age was the only significant risk factor in multivariate analysis (OR 1.02; 95% CI, 1.01-1.04, P = 0.01). 5-year overall survival stratified by stage was as follows: stage IB 88.9%, stage IIA 88.7%, stage IIB 84.2%, stage IIIA 71.7%, stage IIIB 56.8%, stage IIIC 45.4%, and stage IV 25%. Total recurrence rate was 14.4%, which included local recurrence (1.1%) and distant metastases (13.3%). CONCLUSIONS: During our 15 years of experience, we have successfully performed 1483 cases of AGC with laparoscopy. Our results showed short-term and long-term oncologic outcomes that were comparable with other studies. LG is safe and feasible in general practice for advanced gastric cancer when performed by experienced surgeons.

Nutritional safety of oncometabolic surgery for early gastric cancer patients: a prospective single-arm pilot study using a historical control group for comparison.

BACKGROUND: Oncometabolic surgery (OS) is a modification of the Roux-en Y reconstruction method, in which the lengths of the biliopancreatic and Roux limbs are longer than that with conventional surgery (CS). Although OS is performed to improve postoperative glycemic control in gastric cancer patients with type 2 diabetes mellitus (T2DM), its postoperative nutritional safety has not been clarified. This prospective pilot study evaluated the safety and feasibility of OS in early gastric cancer patients. METHODS: This study evaluated 20 patients with clinical T1N0 stage and preoperative body mass index (BMI) ≥ 32.5 kg/m2, or ≥ 27.5 kg/m2 with comorbidities, who underwent OS. Primary outcomes were cumulative incidences of anemia and deficiencies in iron and vitamin B12 after 1 year. The outcomes were compared to those of a matched historical control group. RESULTS: The cumulative incidences of anemia (15.0% vs. 10.0%, P = 0.99), iron deficiency (15.0% vs. 10.0%, P = 0.99), and vitamin B12 deficiency (10.0% vs. 0%, P = 0.47) did not differ significantly in the OS and CS groups. However, median vitamin B12 concentration tended to be lower (395.8 vs. 493.7 pg/mL, P = 0.06) and reductions in vitamin B12 concentration tended to be greater (174.7 vs. 123.0 pg/mL, P = 0.07) in the OS group. BMI loss was similar in the two groups (2.9 vs. 2.8 kg/m2, P = 0.80). Remission rates of hypertension (68.8% vs. 41.2%, P = 0.22) and T2DM (77.8% vs. 50.0%, P = 0.58) were higher in the OS group. CONCLUSION: Nutritional parameters did not differ significantly in the OS and CS groups. Vitamin B12 levels should be carefully monitored after OS.

Internal hernia after gastrectomy for gastric cancer in minimally invasive surgery era.

BACKGROUND: The incidence and clinical presentation of internal hernia after gastrectomy have been changing in the minimally invasive surgery era. This study aimed to analyze the clinical features and risk factors for internal hernia after gastrectomy for gastric cancer. METHODS: We retrospectively analyzed internal hernia after gastrectomy for gastric cancer in 6474 patients between January 2003 and December 2016 at Seoul National University Bundang Hospital. Multivariable logistic regression was performed to evaluate risk factors. RESULTS: Internal hernias identified by computed tomography or surgical exploration were 111/6474 (1.7%) and the median interval time was 450 days after gastrectomy. Fourteen (0.9%) of the 1510 patients who underwent open gastrectomy and 97 (2.0%) of the 4964 patients who underwent laparoscopic gastrectomy developed internal hernia. Of the 6474 patients, internal hernia developed in 0 (0%), 9 (1.1%), 40 (3.1%), 56 (3.3%), 6 (2.3%), and 0 (0%) patients who underwent Billroth I, Billroth II, Roux-en-Y, uncut Roux-en-Y, double tract, and esophagogastrostomy reconstructions, respectively. Fifty-nine (53.2%) of 111 patients with symptomatic hernia underwent surgery. Of the 59 internal hernias, treated surgically, 32 (53.2%), 27 (45.8%), and 0 (0%) were identified in jejunojejunostomy mesenteric, Petersen's, and transverse colon mesenteric defects, respectively. In multivariate analysis, non-closure of mesenteric defects (P < 0.01), laparoscopic approach (P < 0.01), and totally laparoscopic approach (P = 0.03) were independent risk factors for internal hernia. CONCLUSIONS: The potential spaces such as Petersen's, jejunojejunostomy mesenteric, and transverse colon mesenteric defects should be closed to prevent internal hernia after gastrectomy for gastric cancer.

Sentinel node navigation surgery using near-infrared indocyanine green fluorescence in early gastric cancer.

BACKGROUND: The aim of this study was to evaluate the feasibility of indocyanine green (ICG) fluorescent method for sentinel lymph node detection in early gastric cancer. METHODS: Between December 2012 and December 2014, 28 cases of pilot examination were performed at Seoul National University Bundang Hospital. Advanced version of multispectral fluorescence organoscope was used to identify sentinel node by quantitative estimation of ICG fluorescent signal intensity. Sensitivity, specificity, false positive value were analyzed and compared with dual tracer method. RESULTS: A total of 443 lymph nodes in 28 cases were examined and 184 sentinel nodes (41.5%) were identified by dual tracer method. The sensitivity using near-infrared ICG method was 98.9%. The specificity was 76.0% and false positive rate was 25.4% compared with dual tracer method. The adequate threshold for sentinel node detection was considered as 10% of maximum signal intensity. CONCLUSION: New near-infrared ICG fluorescent method could be a promising protocol for sentinel node navigation surgery in early gastric cancer.

Multimodal Enhanced Recovery After Surgery (ERAS) Program is the Optimal Perioperative Care in Patients Undergoing Totally Laparoscopic Distal Gastrectomy for Gastric Cancer: A Prospective, Randomized, Clinical Trial.

BACKGROUND: The application of ERAS protocol has widely gained acceptance after gastrointestinal surgery. Well-designed, randomized, control trials are needed to evaluate fully its safety and efficacy in the field of gastric cancer. This study aims to compare the enhanced recovery after surgery (ERAS) protocol and the conventional perioperative care program after totally laparoscopic distal gastrectomy (TLDG) in gastric cancer. METHODS: Patients with gastric cancer indicated for TLDG were randomly assigned to either the ERAS group or the conventional group. The ERAS protocol included short fasting time, fluid restriction, early oral feeding, immediate mobilization, and use of epidural patient-controlled analgesia. Primary endpoint was recovery time, which was defined with the criteria of tolerable diet, safe ambulation, no requirement of additional analgesics, and afebrile state. Hospital stay, pain score, complications, and readmission rate were secondary endpoints. RESULTS: A total of 97 patients who underwent TLDG from October 2012 to August 2014 were enrolled (ERAS = 46, conventional = 51). The ERAS group had faster recovery time (111.6 ± 34.3 vs. 126.7 ± 30.7 h; p = 0.026) and significantly less pain through postoperative days 1-4. Possible hospital stay also was faster in the ERAS group (5.0 ± 1.9 vs. 5.7 ± 1.6 days, p = 0.038), but there was no difference in actual hospital stay. No difference was found in complication, and there was no mortality or readmission in both groups. CONCLUSIONS: ERAS is safe and enhances postoperative recovery after TLDG in gastric cancer. TRIAL REGISTRATION: The trial was registered in ClinicalTrials.gov (NCT01938313).

Laparoscopic proximal gastrectomy with double tract reconstruction is superior to laparoscopic total gastrectomy for proximal early gastric cancer.

BACKGROUND: Laparoscopic proximal gastrectomy (LPG) with double tract reconstruction (DTR) is known to reduce reflux symptoms, which is a major concern after proximal gastrectomy. The aim of this study is to compare retrospectively the clinical outcomes of patients undergoing LPG with DTR with those treated by laparoscopic total gastrectomy (LTG). METHODS: Ninety-two and 156 patients undergoing LPG with DTR and LTG for proximal stage I gastric cancer were retrospectively analyzed for short- and long-term clinical outcomes. RESULTS: There were no significant differences in the demographics, T-stage, N-stage, and complications between the groups. The LPG with DTR group had a shorter operative time and lower estimated blood loss than the LTG group (198.3 vs. 225.4 min, p < 0.001; and 84.7 vs. 128.3 mL p = 0.001). The incidence of reflux symptoms ≥ Visick grade II did not significantly differ between the groups during a mean follow-up period of 37.2 months (1.1 vs. 1.9%, p = 0.999). The hemoglobin change was significantly lower in the LPG with DTR group compared to in the LTG group in the first and second postoperative years (5.03 vs. 9.18% p = 0.004; and 3.45 vs. 8.30%, p = 0.002, respectively), as was the mean amount of vitamin B12 supplements 2 years after operation (0.1 vs. 3.1 mg, p < 0.001). The overall survival rate was similar between the groups. CONCLUSIONS: LPG with DTR maintained comparable oncological safety and anastomosis-related late complications compared to LTG and is preferred over LTG in terms of preventing postoperative anemia and vitamin B12 deficiency.

Outcomes and recurrence patterns according to breast cancer subtypes in Korean women.

The aim of this study was to evaluate the outcomes and patterns of recurrence in the different subtypes of breast cancer. We analyzed 1432 stage I-III breast cancer patients who had undergone surgery at Seoul National University Bundang Hospital between June 2003 and August 2011. Five subtypes were defined according to estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2 (HER2), and Ki-67. Overall survival (OS) and breast cancer-free interval (BCFI) rates were estimated using the Kaplan-Meier method. Site-specific recurrence was estimated using Gray's test. The median follow-up period was 53 months. There were 22 local recurrences, 18 cases of contralateral breast cancer, 19 regional nodal recurrences, and 70 distant metastases. The 5-year BCFIs by subtype were luminal B-HER2 (+), 94.2 %; luminal A, 93.9 %; luminal B-HER2 (-), 91.4 %; HER2, 83.1 %; and triple-negative, 81.9 % (p < 0.001). Cases with the luminal A had a 5-year OS rate of 98.3 % that was the longest compared to those of cases with luminal B-HER2 (-), 95.8 %; luminal B-HER2 (+), 98.0 %; HER2, 90.8 %; and triple-negative, 89.9 % (p < 0.001). The triple-negative had a higher rate of local recurrence at the first site than others (p = 0.013). HER2 and triple-negative had higher rates of nodal recurrence at the first site than others (p < 0.001). The outcomes and patterns of site-specific recurrence in Korean breast cancer patients were different for each subtype. Defining recurrence patterns by breast cancer subtypes can help determine the appropriate method of surveillance and treatment.

Pharmacokinetic evaluation of paclitaxel, albumin-binding paclitaxel, and liposomal-encapsulated albumin-binding paclitaxel upon gastric subserosal administration.

Introduction: Systemic chemotherapy is typically administered following radical gastrectomy for advanced stage. To attenuate systemic side effects, we evaluated the effectiveness of regional chemotherapy using paclitaxel, albumin-paclitaxel, and liposome-encapsulated albumin-paclitaxel via subserosal injection in rat models employing nuclear medicine and molecular imaging technology. Method: Nine Sprague Dawley rats were divided into three groups: paclitaxel (n = 3), albumin-paclitaxel nano-particles (APNs; n = 3), and liposome-encapsulated APNs (n = 3). [123I]Iodo-paclitaxel ([123I]I-paclitaxel) was synthesized by conventional electrophilic radioiodination using tert-butylstannyl substituted paclitaxel as the precursor. Albumin-[123I]iodo-paclitaxel nanoparticles ([123I]APNs) were prepared using a desolvation technique. Liposome-encapsulated APNs (L-[123I]APNs) were prepared by thin-film hydration using DSPE-PEG2000, HSPC, and cholesterol. The rats in each group were injected with each test drug into the subserosa of the stomach antrum. After predetermined times (30 min, 2, 4, 8 h, and 24 h), molecular images of nuclear medicine were acquired using single-photon emission computed tomography/computed tomography. Results: Paclitaxel, APNs, and L-APNs showed a high cumulative distribution in the stomach, with L-APNs showing the largest area under the curve. Most drugs administered via the gastric subserosal route are distributed in the stomach and intestines, with a low uptake of less than 1% in other major organs. The time to reach the maximum concentration in the intestine for L-APNs, paclitaxel, and APNs was 6.67, 5.33, and 4.00 h, respectively. Conclusion: These preliminary results imply that L-APNs have the potential to serve as a novel paclitaxel preparation method for the regional treatment of gastric cancer.

Laparoscopic fluorescence imaging technique for visualizing biliary structures using sodium fluorescein: the result of a preclinical study in a porcine model.

Purpose: Near-infrared fluorescence imaging has been recently applied in the field of hepatobiliary surgery. Our objective was to apply blue-light fluorescence cholangiography during laparoscopic surgery. Therefore, we designed a preclinical study to evaluate the feasibility of using blue-light fluorescence for cholangiography in a porcine model. Methods: Five millimeters of sodium fluorescein (SF) solution was administered into the gallbladder of 20 male 3-way crossbred (Landrace × Yorkshire × Duroc) pigs in laparoscopic approach. The biliary tree was observed under blue light (a peak wavelength of 450 nm) emitted from a commercialized light-emitting diode (LED) light source (XLS1 extreme, Chammed). Results: In 18 of 20 porcine models, immediately after SF solution was administered into the gallbladder, it was possible to visualize the biliary tree under blue light emitted from the LED light source. Conclusion: This study provided a preclinical basis for using blue-light fluorescence cholangiography using SF in laparoscopic surgery. The clinical feasibility of blue-light fluorescence imaging techniques for laparoscopic cholecystectomy remained to be demonstrated.

First experience of junior surgeons with laparoscopic distal gastrectomy: in view of comparison with experienced surgeons.

INTRODUCTION: Laparoscopic surgery is not easily performed by junior surgeons who have limited experience. AIM: To investigate the safety and feasibility of the first experience of junior surgeons with laparoscopic distal gastrectomy (LDG) who were trained in super high-volume centers. MATERIAL AND METHODS: Clinicopathological data from the first 85 LDG cases performed by three gastric cancer surgeons were collected. All three surgeons were trained for > 1 year in super high-volume centers. The surgical and postoperative outcomes of the first experiences of junior surgeons were compared with the short-term outcomes reported in a multicenter randomized controlled trial (Korean Laparoendoscopic Gastrointestinal Surgery Study, KLASS-01 trial), conducted by the KLASS group, which is composed of experienced surgeons who practice in a high-volume center. RESULTS: A significantly greater number of older patients with longer operation times and lower estimated blood loss was observed for the junior surgeons than in the KLASS data. Although junior surgeons performed significantly more Billroth II anastomoses with D1+ lymph node dissection, there was no difference between the two groups in terms of hospital stay, number of retrieved lymph nodes, or postoperative morbidity. CONCLUSIONS: The surgical outcomes of early gastric cancer managed by laparoscopic surgery performed by well-trained beginners were similar to the outcomes reported in the large-scale trial. Therefore, with regard to the surgical training system, training at super high-volume centers may be considered to provide some assurance in terms of surgical technique-related safety.

Predictive factors affecting percutaneous drainage duration in the percutaneous treatment of common bile duct stones.

The duration of percutaneous transhepatic biliary drainage (PTBD) is a critical factor that determines the duration of treatment. This study aimed to evaluate factors affecting the PTBD duration in patients who underwent percutaneous treatment of common bile duct (CBD) stones. This study analyzed data of 169 patients who underwent percutaneous treatment of CBD stones from June 2009 to June 2019. Demographic data, characteristics of stone, procedure-related factors, and laboratory findings before the insertion of PTBD tubes were retrospectively evaluated. To assess the effect of confounding factors on the PTBD duration, multivariate linear regression analysis was applied, incorporating significant predictive factors identified in the univariate regression analysis. In the univariate regression analysis, the predictive factor that showed high correlation with the PTBD duration was the initial total bilirubin level (coefficient = 0.68, P < .001) followed by the short diameter of the largest stone (coefficient = 0.19, P = .056), and previous endoscopic sphincterotomy (coefficient = -2.50, P = .086). The multivariate linear regression analysis showed that the initial total bilirubin level (coefficient = 0.50, P < .001) and short diameter of the largest stone (coefficient = 0.16, P = .025) were significantly related to the PTBD duration. The total bilirubin level before PTBD tube insertion and the short diameter of the largest CBD stone were predictive factors for the PTBD duration in patients who underwent percutaneous CBD stone removal. Careful assessment of these factors might help in predicting the treatment period, thereby improving the quality of patient care.

Gastrectomy, vitamin B12 supplementation and the risk of Parkinson's disease: A nationwide cohort study.

INTRODUCTION: Previous evidence has suggested roles for α-synuclein propagation and vitamin B12 (VitB12) deficiency in the pathogenesis of Parkinson's disease (PD). We investigated whether gastric cancer (GC) patients who underwent gastrectomy had a lower risk of PD and whether VitB12 supplementation modified the risk. METHODS: GC patients aged ≥50 years who underwent curative gastrectomy between 2007 and 2012 (n = 72,216) and matched comparison groups (n = 211,389) were identified from the Korean National Health Insurance database. The risks of PD were analyzed by Cox regression. RESULTS: Compared to their matched comparison groups, GC patients who underwent gastrectomy showed a decreased risk of PD (adjusted HR [aHR] 0.86; 95% confidence interval [CI] 0.75-0.98), but the significance disappeared after further adjustment with smoking and body mass index (BMI). To elaborate, subtotal gastrectomy (STG) was associated with decreased risk of PD (aHR 0.85; 95% CI 0.74-0.99) while total gastrectomy (TG) was not (aHR 0.89; 95% CI 0.66-1.19), although the risk reduction was not significant when further adjusted for smoking and BMI. Among the patients who underwent TG, their risk of PD was markedly lower when they had VitB12 supplementation after surgery (aHR 0.36; 95% CI 0.17-0.76), while the risk was higher when they did not have any (aHR 1.55; 95% CI 1.03-2.32). CONCLUSIONS: GC patients who underwent gastrectomy and received uninterrupted VitB12 supplementation had a decreased incidence of PD. This study provides indirect epidemiological evidence for the potential roles of gastrectomy and VitB12 in the pathogenesis of PD.

Lymphadenectomy using two instrument arms during robotic surgery for gastric cancer: A strategy to facilitate reduced-port robotic gastrectomy.

BACKGROUND: Three instrument arms are used in the current form of reduced-port robotic gastrectomy (RPRG) for gastric cancer. Based on our experience in performing reduced-port laparoscopic gastrectomy (RPLG), we have recently performed RPRG using two instrument arms. METHODS: From February 2018 to January 2019, we performed RPRG using two instrument arms for gastric cancer. One endoscope arm and two instrument arms of da Vinci® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) were applied in robotic lymphadenectomy. A commercial multi-lumen single-port trocar was used for the endoscopy port. RESULTS: A total of 18 patients underwent the planned robotic surgery using two instrument arms. Median operation time was 288.5 (213.0-446.0) minutes, and median hospital stay was 11.0 (7-18) days. Four patients experienced postoperative complications: one Clavien-Dindo grade IIIa, and the other three grade II. No mortality was reported. The number of retrieved lymph nodes did not differ between patients who underwent RPRG and RPLG (p = 0.412). CONCLUSION: Gastric cancer surgery using two instrument arms of a robotic surgical system can be performed by surgeons with expertise of RPLG. If this technique is successfully introduced in robotic surgery, it is expected to shorten the path to pure single-port robotic gastrectomy.

Comparison of the Clinical Outcomes Between Isoperistaltic and Antiperistaltic Anastomoses After Laparoscopic Distal Gastrectomy for Patients With Gastric Cancer.

Background: No consensus exists regarding the superiority of either of the two types of gastrointestinal anastomosis, which are isoperistaltic and antiperistaltic. This study aimed to compare the clinical outcomes between isoperistaltic and antiperistaltic anastomoses after total laparoscopic distal gastrectomy (TLDG) in patients with gastric cancer. Methods: We retrospectively reviewed the medical records of patients with gastric cancer who underwent TLDG with Billroth II anastomosis between January 2014 and December 2018. The patients were divided into two groups according to the peristaltic direction of gastrointestinal anastomosis after TLDG. One group underwent isoperistaltic anastomosis (Iso group), and the other underwent antiperistaltic anastomosis (Anti group). Clinical outcomes were compared between the groups. Results: Of the 148 patients who underwent TLDG with Billroth II anastomosis, 124 were included in the Iso group and 24 were included in the Anti group. The Anti and Iso groups showed no significant difference with regard to the incidence of internal hernia (0.0 vs. 6.5%, respectively; p = 0.355). The incidence of bile reflux was more frequent in the Iso group than in the Anti group (p = 0.010), but food stasis was more common in the Anti group than in the Iso group (p = 0.006). Conclusion: In gastric cancer patients who underwent TLDG in which postoperative adhesion was minimized, antiperistaltic anastomosis may have created a physiologic barrier in gastrointestinal continuity. However, a large-scale study is necessary to validate the relationship between the digestive stream and the peristaltic direction.

Long-term Outcomes of Laparoscopic Versus Open Transhiatal Approach for the Treatment of Esophagogastric Junction Cancer.

PURPOSE: The laparoscopic transhiatal approach (LA) for adenocarcinoma of the esophagogastric junction (AEJ) is advantageous since it allows better visualization of the surgical field than the open approach (OA). We compared the surgical outcomes of the 2 approaches. MATERIALS AND METHODS: We analyzed 108 patients with AEJ who underwent transhiatal distal esophagectomy and gastrectomy with curative intent between 2003 and 2015. Surgical outcomes were reviewed using electronic medical records. RESULTS: The LA and OA were performed in 37 and 71 patients, respectively. Compared to the OA, the LA was associated with significantly shorter duration of postoperative hospital stay (9 vs. 11 days, P=0.001), shorter proximal resection margins (3 vs. 7 mm, P=0.004), and extended operative times (240 vs. 191 min, P=0.001). No significant difference was observed between the LA and OA for intraoperative blood loss (100 vs. 100 mL, P=0.392) or surgical morbidity rate (grade≥II) for complications (8.1% vs. 23.9%, P=0.080). Two cases of anastomotic leakage occurred in the OA group. The number of harvested lymph nodes was not significantly different between the LA and OA groups (54 vs. 51, P=0.889). The 5-year overall and 3-year relapse-free survival rates were 81.8% and 50.7% (P=0.024) and 77.3% and 46.4% (P=0.009) for the LA and OA groups, respectively. Multivariable analyses revealed no independent factors associated with overall survival. CONCLUSIONS: The LA is feasible and safe with short- and long-term oncologic outcomes similar to those of the OA.

Long-term Survival Outcomes of Laparoscopic Gastrectomy for Advanced Gastric Cancer: Five-year Results of a Phase II Prospective Clinical Trial.

PURPOSE: Despite an increased acceptance of laparoscopic gastrectomy (LG) in early gastric cancer (EGC), there is insufficient evidence for its oncological safety in advanced gastric cancer (AGC). This is a prospective phase II clinical trial to evaluate the feasibility of LG with D2 lymph node dissection (LND) in AGC. MATERIALS AND METHODS: The primary endpoint was set as 3-year disease-free survival (DFS). The eligibility criteria were as follows: 20-80 years of age, cT2N0-cT4aN3, American Society of Anesthesiologists score of 3 or less, and no other malignancy. Patients were enrolled in this single-arm study between November 2008 and May 2012. Exclusion criteria included cT4b or M1, or having final pathologic results as EGC. All patients underwent D2 lymphadenectomy. Three-year DFS rates were estimated by the Kaplan-Meier method. RESULTS: A total of 157 patients were enrolled. The overall local complication rate was 10.2%. Conversion to open surgery occurred in 11 patients (7.0%). The mean follow-up period was 55.0±20.4 months (1-81 months). The cumulative 3-year DFS rates were 76.3% for all stages, and 100%, 89.3%, 100%, 88.0%, 71.4%, and 35.3% for stage IB, IIA, IIB, IIIA, IIIB, and IIIC, respectively. Recurrence was observed in 37 patients (23.6%), including hematogenous (n=6), peritoneal (n=13), locoregional (n=1), distant node (n=8), and mixed recurrence (n=9). CONCLUSIONS: In addition to being technically feasible for treatment of AGC in terms of morbidity, LG with D2 LND for locally advanced gastric cancer showed acceptable 3-year DFS outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01441336.

Comparison of Short-Term Outcomes Using Three-Dimensional and Two-Dimensional Laparoscopic Gastrectomy for Gastric Cancer.

Introduction: This study investigated the oncological and technical advantages of three-dimensional (3D) versus two-dimensional (2D) laparoscopic gastric cancer surgery. Materials and Methods: This study included 68 gastric cancer patients who had undergone laparoscopic distal gastrectomy at Korea University Ansan Hospital (3D group, n = 34; 2D group, n = 34). The surgical outcomes and duration of each phase were compared between the groups. Results: The total operative time with 3D laparoscopy was significantly shorter than with 2D laparoscopy (227.8 ± 39.0 versus 249.6 ± 45.3 minutes; P = .037). There were no significant differences between the groups in the number of gauze pads used, time to first postoperative flatus, and number of harvested lymph nodes (2.0 [1.0-2.0] versus 2.0 [1.0-2.0]; P = .692; 4.0 [4.0-4.0] versus 4.0 [4.0-4.0] days; P = .196; 40.8 ± 16.6 versus 44.0 ± 15.7; P = .412, respectively). The time from omentectomy to right gastric artery ligation and the duration of the reconstruction phase were shorter with 3D than with 2D laparoscopy (62.6 ± 14.5 versus 71.9 ± 18.8 minutes; P = .027; 32.3 ± 7.6 versus 47.7 ± 16.8 minutes; P < .001). Conclusion: In a procedure requiring spatial perception, the operative time was shortened by introducing 3D laparoscopy. Despite the anticipation of a better view for lymph node dissection, the 3D image showed no advantage. Further study may be required by novice surgeons.

Laparoscopic Treatment of Gastric Subepithelial Tumor: Finding Ways to Manage with Shorter Hospitalization Days.

Purpose: The standard treatment for gastric subepithelial tumor (SET) is surgical resection, which is primarily performed via laparoscopy. The aims of this study were firstly to evaluate factors influencing morbidity and hospitalization after treatment of gastric SET, and secondly, to figure out the factors how to make shorter hospitalization with equal safety. Methods: We retrospectively enrolled 229 consecutive patients who underwent laparoscopic gastric wedge resection (LGWR) for gastric SET between August 2003 and December 2015. Patients were divided into two groups: the 3 days or less hospitalization group (N=82, group A) and the greater than 3 days hospitalization group (N=147, group B). Results: Median tumor size was 3.0 cm (range, 0.2~13.0 cm) and mean postoperative hospitalization was 4.27±2.15 days. There were 6 complications (2.6%), with no cases of mortality. In group A, tumors were smaller (3.0±1.1 cm vs. 3.6±1.9 cm, p<0.01) and more likely to be located on the greater curvature (28% vs. 15%, p<0.01) compared with group B. The tumor growth pattern (exophytic tumor: 72% in group A vs. 65% in group B, p=0.25) was not different between the two groups. Multivariate analysis showed that tumor size larger than 5 cm and posterior wall tumor location were risk factors for longer hospital stay. Conclusion: We could reduce the hospitalization of patients with gastric SET less than 5cm sized and located on other than the posterior wall within 3days. Those patients could be a candidate for day surgery.

Multi-DOF (Degree of Freedom) Articulating Laparoscopic Instrument is an Effective Device in Performing Challenging Sutures.

Purpose: Although laparoscopic surgery had been performed in clinical practice for over 30 years, there has not been much improvement on instruments. Several articulating laparoscopic instruments have been developed including the robotic system. A new multi-degree of freedom (DOF) articulating laparoscopic device has been developed. We compared the ability to perform challenging sutures between the new device and the robotic system. Methods: Five experienced surgeons with over 100 laparoscopic surgery cases performed the suture task with both instruments. Everyone was new at articulating instruments including a robotic system. The suturing task consisted of two vertical sutures, downward and upward vertical direction. The duration of needle grabbing, first surgical tie, square tie, and the final reverse tie was measured. Results: When doing the downward suture, the median time to complete the suture was 127 vs. 136 seconds for ArtiSential® and the robot, respectively (p=0.754). Other measurements such as needle grabbing, first tie, second tie and final knot did not show any significant difference between the two instruments. Upward suture also did not show a significant difference. The total completion time was 127 vs. 112 seconds for for ArtiSential® and the robot, respectively (p=0.675). Time taken in each interval did not show any significant difference. Conclusion: Both instruments performed the suturing tasks with no difference in duration. ArtiSential® can be mixed up with usual instruments. Surgeons can choose any device, but when articulation is needed, ArtiSential® could be an alternative choice to the robotic system.

Rapid Staining Using the Shorr Method for Intraoperative Peritoneal Washing Cytology in Advanced Gastric Cancer: a Pilot Study from a Single Institution.

PURPOSE: Intraoperative peritoneal washing cytology (PWC) is used to determine treatment strategies for gastric cancer with suspected serosal invasion. However, a standard staining method for intraoperative PWC remains to be established. We evaluated the feasibility of a rapid and simple staining method using Shorr's stain for intraoperative PWC in advanced gastric cancer. MATERIALS AND METHODS: Between November 2012 and December 2014, 77 patients with clinical T3 or higher gastric cancer were enrolled. The sensitivity, specificity, and concordance between the Shorr staining method and conventional Papanicolaou (Pap) staining with carcinoembryonic antigen (CEA) immunohistochemistry (IHC) were analyzed. RESULTS: Intraoperative PWC was performed laparoscopically in 69 patients (89.6%). The average time of the procedure was 8.3 minutes, and the average amount of aspirated fluids was 83.3 mL. The average time for Shorr staining and pathologic review was 21.0 minutes. Of the 77 patients, 16 (20.7%) had positive cytology and 7 (9.1%) showed atypical findings; sensitivity and specificity were 73.6% and 98.2% for the Shorr method, and 78.9% and 98.2% for the Pap method with CEA IHC, respectively. Concordance of diagnosis between the 2 methods was observed in 90.9% of cases (weighted κ statistic=0.875) and most disagreements in diagnoses occurred in atypical findings (6/7). In overall survival, there was no significant difference in C-index between the 2 methods (0.459 in Shorr method vs. 0.458 in Pap with CEA IHC method, P=0.987). CONCLUSIONS: Shorr staining could be a rapid and reliable method for intraoperative PWC in advanced gastric cancer.