Three-dimensional Stereoscopic Visualization Shortens Operative Time in Laparoscopic Gastrectomy for Gastric Cancer.
ABSTRACT: Laparoscopic gastrectomy for gastric cancer is now widely accepted and has become a standard surgery. This study investigated the advantages of three-dimensional (3D) stereoscopic visualization for laparoscopic gastrectomy over a conventional two-dimensional (2D) planar screen. The primary outcome of this study was operative time. Ninety-four consecutive cases of gastric cancer patients who underwent laparoscopic total gastrectomy (LTG) (25 cases) or laparoscopic distal gastrectomy (LDG) (69 cases) were enrolled in this study before and after the introduction of the 3D system. Operative time was significantly shorter in the 3D groups for both LTG (351 vs. 406?min, P?=?0.026) and LDG (269 vs. 344?min, P?
Project description:To investigate the safety and efficiency of using robotic staplers for intracorporeal gastroduodenostomy in reduced-port robotic gastrectomy for gastric adenocarcinoma. We retrospectively reviewed patients who underwent totally robotic and laparoscopic gastrectomy with intracorporeal gastroduodenostomy. Gastroduodenostomy using the ENDOWRIST robotic stapler (RR) was compared to that using an endolinear stapler during robotic gastrectomy (RE) and to that using an endolinear stapler during laparoscopic gastrectomy (LE). A total of 296 patients underwent gastroduodenostomy: 58, 28, and 210 patients with RR, RE, and LE, respectively. There were no conversions to other methods, and all robotic stapling procedures were performed on the console without receiving additional assistance from a bedside surgeon during RR. Comparing the operative outcomes of RR with those of RE and LE, respectively, we noted similar postoperative short-term outcomes. There were no major complications, including anastomosis-related complications, during the postoperative period after RR. The median reconstruction time during RR was 8 min and 45 s, which was similar to that during RE (8 min, 5 s [P?>?0.9999]), but longer than that during LE (6 min, 30 s [P?<?0.0001]). Intracorporeal gastroduodenostomy using the robotic stapler during robotic gastrectomy could be safely and feasibly performed on the console without the assistance of assistant, bedside surgeons.
Project description:BACKGROUND:There is no consensus regarding which reconstruction methods are superior after laparoscopic distal gastrectomy (LDG). This study compared four reconstruction methods after LDG for gastric cancer. METHODS:Literature in EMBASE, PubMed, and the Cochrane Library was screened to compare Billroth I (B-I), Billroth II (B-II), Roux-en-Y (RY), and uncut Roux-en-Y (URY) anastomoses after LDG for gastric cancer. A Bayesian network meta-analysis (NMA) was conducted to compare these methods. RESULTS:Eighteen studies involving 4347 patients were eligible for our NMA. The operative time in RY anastomosis was longer than that in B-I and B-II anastomoses. Blood loss and risk of gastrointestinal motility dysfunction were greater with RY anastomosis than with URY or B-I anastomosis. Furthermore, URY anastomosis was superior to the other 3 reconstruction methods for preventing food residue. For remnant gastritis, RY anastomosis was significantly superior to B-I and B-II anastomoses, whereas URY anastomosis was significantly superior to B-II anastomosis. In addition, RY and URY anastomoses were better than B-I and B-II anastomoses for preventing bile reflux. CONCLUSIONS:URY anastomosis tended to be a more favorable reconstruction method after LDG due to its operative simplicity and reduced long-term complications.
Project description:BACKGROUND: Billroth I (B-I) gastroduodenostomy is an anastomotic procedure that is widely performed after gastric resection for distal gastric cancer. A circular stapler often is used for B-I gastroduodenostomy in open and laparoscopic-assisted distal gastrectomy. Recently, totally laparoscopic distal gastrectomy (TLDG) has been considered less invasive than laparoscopic-assisted gastrectomy, and many institutions performing laparoscopic-assisted distal gastrectomy are trying to progress to TLDG without markedly changing the anastomosis method. The purpose of this report is to introduce the technical details of new methods of intracorporeal gastroduodenostomy using either a circular or linear stapler and to evaluate their technical feasibility and safety. METHODS: Seventeen patients who underwent TLDG with the intracorporeal double-stapling technique using a circular stapler (n = 7) or the book-binding technique (BBT) using a linear stapler (n = 10) between February 2010 and April 2011 were enrolled in the study. Clinicopathological data, surgical data, and postoperative outcomes were analyzed. RESULTS: There were no intraoperative complications or conversions to open surgery in any of the 17 patients. The usual postoperative complications following gastroduodenostomy, such as anastomotic leakage and stenosis, were not observed. Anastomosis took significantly longer to complete with DST (64 ± 24 min) than with BBT (34 ± 7 min), but more stapler cartridges were needed with BBT than with DST. CONCLUSIONS: TLDG using a circular or linear stapler is feasible and safe to perform. DST will enable institutions performing laparoscopic-assisted distal gastrectomy with circular staplers to progress to TLDG without problems, and this progression may be more economical because fewer stapler cartridges are used during surgery. However, if an institution has already been performing ? anastomosis in TLDG but has been experiencing certain issues with ? anastomosis, converting from ? anastomosis to BBT should be beneficial.
Project description:Laparoscopic proximal gastrectomy (LPG) is theoretically a superior choice of minimally-invasive surgery and function-preserving surgery for the treatment of proximal early gastric cancer (EGC) over procedures such as laparoscopic total gastrectomy (LTG), open total gastrectomy (OTG) and open proximal gastrectomy (OPG). However, LPG and OPG are not popular surgical options due to three main concerns: the first, oncological safety; the second, functional benefits; and the third, anastomosis-related late complications (reflux symptoms and anastomotic stricture). Numerous recent studies have concluded that OPG and LPG present similar oncological safety profiles and improved functional benefits when compared with OTG and LTG. While OPG with modified esophagogastrostomy does not provide satisfactory results, OPG with modified esophagojejunostomy showed similar rates of anastomosis-related late complications when compared to OTG. At this stage, no standard reconstruction method post-LPG exists in the clinical setting. We recently showed that LPG with double tract reconstruction (DTR) is a superior choice over LTG for proximal EGC in terms of maintaining body weight and preventing anemia. However, as there is no definitive evidence in favor of LPG with DTR, a randomized clinical trial comparing LPG with DTR to LTG was recommended. This trial, the Korean Laparoscopic Gastrointestinal Surgery Study-05 (NCT01433861), is expected to assist surgeons in choice of surgical approach and strategy for patients with proximal EGC.
Project description:<h4>Purpose</h4>It is hypothesized that robotic gastrectomy may surpass laparoscopic gastrectomy after the operators acquire long-term experience and skills in the manipulation of robotic arms. This study aimed to evaluate the long-term learning curve of robotic distal gastrectomy (RDG) for gastric cancer compared with laparoscopic distal gastrectomy (LDG).<h4>Materials and methods</h4>From October 2008 to December 2015, patients who underwent LDG (n=809) were matched to patients who underwent RDG (n=232) at a 1:1 ratio, by using a propensity score matching method after stratification for the operative year. The surgical outcomes, such as trends of operative time, blood loss, and complication rate, were compared between the two groups.<h4>Results</h4>The RDG group showed a longer operative time (171.3 minutes vs. 147.6 minutes, P<0.001) but less estimated blood loss (77.6 ml vs. 116.6 ml, P<0.001). The complication rate and postoperative recovery did not differ between the two groups. The RDG group showed a longer operative time and similar estimated blood loss compared with the LDG group after 5 years of experience (operative time: 159.2 minutes vs. 136.0 minutes in 2015, P=0.003; estimated blood loss: 72.9 ml vs. 78.1 ml in 2015, P=0.793).<h4>Conclusions</h4>In terms of short-term surgical outcomes, RDG may not surpass LDG after a long-term experience with the technique.
Project description:BACKGROUND:Laparoscopic ileostomy closure with intracorporeal anastomosis offers potential advantages over open reversal with extracorporeal anastomosis, including earlier return of bowel function and reduced postoperative pain. In this study, we aim to compare the outcome and cost of laparoscopic ileostomy reversal (utilizing either intracorporeal or extracorporeal anastomosis) with open ileostomy reversal. METHODS:A retrospective review of sequential patients undergoing elective loop ileostomy reversal between 2013 and 2016 at a single, high-volume institution was performed. Patients were stratified on the basis of operative approach: open reversal, laparoscopic-assisted reversal with extracorporeal anastomosis (LE), and laparoscopic reversal with intracorporeal anastomosis (LI). Linear and logistic regressions were utilized to perform multivariate analysis and determine risk-adjusted outcomes. RESULTS:Of 132 sequential cases of loop ileostomy reversal, 50 (38%) underwent open, 49 (37%) underwent LE, and 33 (22%) underwent LI. Demographic data and preoperative comorbidities were similar between the three cohorts. Median length of stay was significantly shorter for LI (52.1 h, p?<?0.05) compared to open (69.0 h) and LE (69.6 h). After risk-adjusted analysis, length of stay was significant shorter in LI compared to LE (GM 0.78, 95% CI 0.64-0.93, p?<?0.01) and open reversal (GM 0.78, 95% CI 0.66-0.93, p?<?0.01). Risk-adjusted 30-day morbidity rates were similar for LI compared to LE (OR 0.43, 95% CI 0.081-2.33, p?=?0.33) and open reversal (OR 0.53, 95% CI 0.09-3.125, p?=?0.48). Median in-hospital direct cost was similar for LI ($6575.00), LE ($6722.50), and open reversal ($6181.00). CONCLUSION:Laparoscopic ileostomy reversal with intracorporeal anastomosis was associated with shorter length of stay without increased overall direct cost. The technique of laparoscopic ileostomy reversal warrants continued study in a randomized clinical trial.
Project description:<h4>Purpose</h4>Laparoscopic total gastrectomy (LTG) is more complicated than laparoscopic distal gastrectomy, especially during a surgeon's initial experience with the technique. In this study, we evaluated the short-term outcomes of and learning curve for LTG during the initial cases of a single surgeon compared with those of open total gastrectomy (OTG).<h4>Materials and methods</h4>Between 2009 and 2013, 134 OTG and 74 LTG procedures were performed by a single surgeon who was experienced with OTG but new to performing LTG. Clinical characteristics, operative parameters, and short-term postoperative outcomes were compared between groups.<h4>Results</h4>Advanced gastric cancer and D2 lymph node dissection were more common in the OTG than LTG group. Although the operation time was significantly longer for LTG than for OTG (175.7±43.1 minutes vs. 217.5±63.4 minutes), LTG seems to be slightly superior or similar to OTG in terms of postoperative recovery measures. The operation time moving average of 15 cases in the LTG group decreased gradually, and the curve flattened at 54 cases. The postoperative complication rate was similar for the two groups (11.9% vs. 13.5%). No anastomotic or stump leaks occurred.<h4>Conclusions</h4>Although LTG is technically difficult and operation time is longer for surgeons experienced in open surgery, it can be performed safely, even during a surgeon's early experience with the technique. Considering the benefits of minimally invasive surgery, LTG is recommended for early gastric cancer.
Project description:BACKGROUND:Delta-shaped anastomosis is a common method of intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy. One common postoperative complication of this procedure is anastomotic stenosis, and endoscopic balloon dilatation is a major remedy for such complications. Other treatment strategies are necessary to manage unsuccessful endoscopic balloon dilatation. CASE PRESENTATION:We present a case where systemic steroid treatment was applied in sustained anastomotic stenosis after endoscopic balloon dilatation. We performed delta-shaped anastomosis in laparoscopic distal gastrectomy to treat early-stage gastric cancer in a patient. The patient experienced abdominal pain post-surgery; subsequent investigation revealed edematous anastomotic stenosis. The stenosis sustained even after endoscopic balloon dilatation and local steroid injection. Consequently, we applied systemic steroid treatment. CONCLUSION:Systemic steroid treatment improved the stenosis and no recurrence was observed. These results suggest that systemic steroid application could be useful to treat anastomotic stenosis.
Project description:BACKGROUND:The safety of laparoscopic total gastrectomy (LTG) for the treatment of gastric cancer remains lack of clinical evidence. The Chinese Laparoscopic Gastrointestinal Surgery Study (CLASS) Group recently launched a multicenter randomized clinical trial (CLASS02-01) to compare the safety of LTG for clinical stage I gastric cancer with the conventional open total gastrectomy (OTG). METHODS:This CLASS02-01 trial is a prospective, multicenter, randomized, controlled, open, and non-inferiority trial. Two hundred patients who met the inclusion criteria and did not accord with the exclusion criteria will be randomly divided into LTG group (n?=?100) and OTG group (n?=?100). The primary purpose of this study is to evaluate the early operative morbidity and mortality of LTG compared with OTG for clinical stage I gastric adenocarcinoma. The second purpose is to evaluate the recovery course and compare the postoperative hospital stay of the patients enrolled in this study. DISCUSSION:This CLASS02-01 trial is the first prospective randomized two-arm controlled study to determine the safety of LTG compared with OTG. Through this trial, we hope to show that experienced surgeons can safely perform LTG with lymphadenectomy for gastric cancer. TRIAL REGISTRATION:ClinicalTrials.gov ID: NCT03007550 . December 30, 2016.
Project description:BACKGROUND:Contemporary 3D platforms have overcome past deficiencies. Available trainee and laboratory studies suggest stereoscopic imaging improves performance but there is little clinical data or studies assessing specialists. We aimed to determine whether stereoscopic (3D) laparoscopic systems reduce operative time and number of intraoperative errors during specialist-performed laparoscopic cholecystectomy (LC). METHODS:A parallel arm (1:1) randomised controlled trial comparing 2D and 3D passive-polarised laparoscopic systems in day-case LC using was performed. Eleven consultant surgeons that had each performed?>?200 LC (including?>?10 3D LC) participated. Cases were video recorded and a four-point difficulty grade applied. The primary outcome was overall operative time. Subtask time and the number of intraoperative consequential errors as identified by two blinded assessors using a hierarchical task analysis and the observational clinical human reliability analysis technique formed secondary endpoints. RESULTS:112 patients were randomised. There was no difference in operative time between 2D and 3D LC (23:14 min (±?10:52) vs. 20:17 (±?9:10), absolute difference - 14.6%, p?=?0.148) although 3D surgery was significantly quicker in difficulty grade 3 and 4 cases (30:23 min (±?9:24), vs. 18:02 (±?7:56), p?<?0.001). No differences in overall error count was seen (total 47, median 1, range 0-4 vs. 45, 1, 0-3, p?=?0.62) although there were significantly fewer 3D gallbladder perforations (15 vs. 6, p?=?0.034). CONCLUSION:3D laparoscopy did not reduce overall operative time or error frequency in laparoscopic cholecystectomies performed by specialist surgeons. 3D reduced Calot's dissection time and operative time in complex cases as well as the incidence of iatrogenic gallbladder perforation (NCT01930344).