Our results confirm the feasibility of LCTG for the treatment of GSC. Patients in the LCTG group had significantly longer operation times but significantly less blood loss and earlier flatus passage than the OCTG group. Furthermore, no conversion to open surgery and no higher morbidity than Clavien Dindo class III were reported in the LCTG group.
Yamada et al. [24] were the first to present a case report for laparoscopy-assisted resection of gastric remnant cancer in 2005; many additional studies reported successful applications of the technique [25–33]. Therefore, we searched reports of LCTG for GSC from the PubMed database in English literature and summarized the data by case reports (Table 5) and comparative studies (Table 6). Many surgeons have successfully applied LCTG, and this technique is considered the preferred treatment option (Table 5) [24–33]. As shown in Table 6, our results are consistent with those of comparative studies [14–21].
Table 5
Summary of Case Reports of LCTG for GSC
Hospital stay | (days) | - | | 11 (8–18) | | - | | - | | 8.8 (8–9) | | 8 (7–9) | | 13 | | 18 (13–26) | | 7 | | 10 |
Retrieved LN | (n) | - | | 18 (12–26) | | 14.5 (9–20) | | 18 ± 5 | | 18.2 (12–24) | | 16.7 (10–22) | | 24 | | - | | 20 | | - |
Morbidity (C-D III>) | (n) | - | | fistula (1) | | - | | SSI (1) | | - | | - | | - | | bleeding (1) | | - | | - |
Open conversion | (n) | - | | - | | - | | 1 | | - | | - | | - | | - | | - | | - |
Blood loss | (ml) | 30 | | 19 (0-264) | | 425 (400–450) | | 110 ± 40 ml | | 63.6 (10–233) | | 76.7 (50–100) | | 100 | | 270.3 (33–500) | | 200 | | 40 |
Operation time | (min) | 274 | | 210 (160–260) | | 487.5 (435–540) | | 205 ± 25 min | | 370.8 (258–540) | | 251.7 (225–280) | | 200 | | 413.3 (367–488) | | 295 | | 395 |
interval | (yrs) | 10 | | 15 | | 1.5 | | - | | - | | 22 (6–30) | | 28 | | 19 (0.08-50) | | 25 | | 7 |
Previous reconstruction | BII | | BII (3) | | BII (2) | | BI (2) / BII (13) | | BI (3) / BII (2) | | BII (2) / RY (1) | | BII | | BI (2) / BII (1) / RY (1) | | GJ with braun | | jejunal interposition |
previous ope | (Open / Lap) | 1 / 0 | | 3 / 0 | | 1 / 1 | | - | | - | | 3 / 0 | | 1 / 0 | | 3 / 1 | | 1 / 0 | | 1 / 0 |
initial disease | (B / M) | 0 / 1 | | 3 / 0 | | 0 / 1 | | - | | 1 / 4 | | 2 / 1 | | 0 / 1 | | 1 / 3 | | 0 / 1* | | 0 / 1 |
gender | (M / F) | 1 / 0 | | 3 / 0 | | 1 / 1 | | 13 / 2 | | 3 / 2 | | 3 / 0 | | 0 / 1 | | 4 / 0 | | 1 / 0 | | 1 / 0 |
age | | 69 | | 59–73 | | 37 / 68 | | 53.5 (40–76) | | 54–84 (70.4) | | 68.7 (55–76) | | 83 | | 76.5 (62–83) | | 73 | | 72 |
n | | 1 | | 3 | | 2 | | 15 | | 5 | | 3 | | 1 | | 4 | | 1 | | 1 |
Year | | 2005 | | 2008 | | 2009 | | 2010 | | 2013 | | 2014 | | 2015 | | 2015 | | 2016 | | 2016 |
Author | | Yamada. H, et al. | | Corcione. F, et al. | | Cho. HJ, et al. | | Qian F, et al. | | Shinohara. T, et al. | | Pan et al. | | Kim HI, et al. | | Korehisa S, et al. | | Kim DJ, et al. | | Yajima. K, et al. |
M male, F female, B benign, M malignant, Lap laparoscopy, LN lymph node, C-D III > clavien dindo classification III>, BI BillrothI, BII BillrothII, RY Roux-en Y, GJ gastrojejunostomy, * common bile duct cancer |
Table 6
Summary of Comparative Studies of LCTG for GSC
OS | | 77.8% (3 year) | 100% | | 94.9% (5 year) | 100% | | | | | 66.7% (5 year) | 60.30% | | | | | 94% (5 year) | | | | | | | | | 88.2% (5 year)* | 55.00% |
Hospital stay | (days) | 11.3 ± 2.8 * | 24.9 ± 10 | | 6 (5–44) * | 9 (6–28) | | 11.1 ± 8.7 | 13.8 ± 9.4 | | 9.3 ± 3.2 | 9.3 ± 3.1 | | 12.5 ± 2.7 | 24 | | 15 | 16 | | 10.6 ± 3.7 | 21.3 ± 37.3 | | 13 ± 5 | 27 ± 21 | | 14.8 ± 5.1 | 29.1 ± 56.3 |
Retrieved LN | (n) | 23.7 ± 10.7 | 15.9 ± 7.6 | | 8 (0–37) | 7 (0–36) | | 12.9 ± 8.7 | | | 18.8 ± 12.3 | 22.3 ± 14.4 | | 22.4 ± 15.0 | 7 | | 15 | 11 | | 8.8 ± 4.6 | 6.0 ± 6.9 | | 22 ± 13 | 12 ± 9 | | 14.8 ± 11.9 | 12.0 ± 10.4 |
Morbidity (C-D III>) | (%) | 0 | 2 (20) | | 3 (16.7) | 9 (15.5) | | 4 (23.5) | 15 (30) | | 1 (5.9) | 1 (5.9) | | 0 | 2(33) | | 2 (50) | 5 (27.8) | | 3 (37.5) | 6 (26.1) | | 2 (28.6) | 10 (50) | | 0 | 2 (10) |
Open conversion | (%) | 0 | - | | 1 (5.6) | - | | 0 | - | | 8 (47.1) | - | | 0 | - | | 0 | - | | 2 (25) | - | | 0 | - | | 0 | - |
Blood loss | (ml) | 65.8 ± 62.0 | 746.3 ± 577.1* | | 182.2 ± 188.7 | 193.1 ± 227.6 | | | | | 227.6 ± 245.0 | 184.1 ± 123.1 | | 55.4 ± 60.7 | 893 | | 158 | 625 | | 135.5 ± 181.2 * | 568.3 ± 446.4 | | 70 ± 71 * | 1066 ± 1428 | | 24.4 ± 27.0 * | 212.5 ± 230.8 |
Operation time | (min) | 362.3 ± 68.4 * | 270.5 ± 94.9 | | 266.2 ± 77.2* | 203.3 ± 52.2 | | 197.2 ± 60.6* | 149.3 ± 46.9 | | 234.4 ± 65.2* | 170.0 ± 39.5 | | 324.5 ± 40.6 | 289 | | 455 * | 293 | | 307.5 ± 56.0 | 295.8 ± 81.7 | | 364 ± 95 | 309 ± 104 | | 242.6 ± 64.8 | 202.5 ± 67.6 |
previous ope | (Open / Lap) | 12 / 0 | 10 / 0 | | 11 / 7* | 54 / 4 | | 10 / 7 | | | 11 / 6* | 17 / 0 | | 10 / 0 | | | | | | 5 / 3 | 21 / 2 | | 6 / 1 | 18 / 2 | | 11 / 6 | 17 / 3 |
initial disease | (B / M) | 7 / 5 | 2 / 8 | | 2 / 16 | 12 / 46 | | 0 / 17 | 0 / 50 | | 7 / 10 | 6 / 11 | | 4 / 6 | | | 6 / 16 | | | 4 / 4 | 6 / 17 | | 5 / 2 | 11 / 9 | | 5 / 12 | 4 / 16 |
n | | 12 | 10 | | 18 | 58 | | 17 | 50 | | 17 | 17 | | 10 | 6 | | 4 | 18 | | 8 | 23 | | 7 | 20 | | 17 | 20 |
LCTG | OCTG | Lap | Open | | Lap | Open | | Lap | Open | | Lap | Open | | Lap | Open | | Lap | Open | | Lap | Open | | Lap | Open | | Lap | Open |
Year | | 2014 | | | 2014 | | | 2014 | | | 2015 | | | 2016 | | | 2019 | | | 2019 | | | 2019 | | | 2020 | |
Author | | Nagai E, et al. | | | Kwon IG, et al. | | | Kim HS, et al. | | | Son SY, et al. | | | Tsunoda S, et al. | | | Nakaji Y, et al. | | | Booka E, et al. | | | Otsuka R, et al. | | | our data | |
LCTG laparoscopic completion total gastrectomy, GSC gastric stump cancer, OCTG open completion total gastrectomy, B benign disease, M malignant disease, Lap laparoscopy, C-D III > clavien dindo classification III>, LN lymph node, OS overall survival, * P value < 0.05 |
The patients in the LCTG group had smaller tumor size, lower numbers of metastatic lymph nodes, and lower pathological stages than patients in the OCTG group; however, the clinical stage distribution, dissection, and retrieved lymph nodes showed no significant differences between the groups. Additionally, the number of retrieved lymph nodes was equal to that reported in other studies (Table 6) [14–21]. The OCTG group had a higher number of recurrences and deaths than the LCTG group, because the OCTG group had more advanced cases, leading to a worse 5-year overall survival rate than the LCTG group. Recently, the number of lower stages of GSC has been increasing due to the strict postoperative surveillance for PGC; this surveillance combined with the feasibility and validity of LCTG can improve patient survival [7].
The most difficult part of the operative procedure for GSC is the adhesiolysis, which is the key factor to safely performing LCTG [18]. A precise and sharp dissection between the adjacent organ and remnant stomach is necessary to avoid organ injury, and less bowel manipulation leads to early recovery [15, 18]. We consider laparoscopy an effective solution to overcome this difficulty in the treatment of GSC. The advantages of laparoscopic surgery are pneumoperitoneum, which widens the dissectible layer between the adhered organs, and a magnified view that enables detection of the loose and dissectible layer. Moreover, progressive high definition (HD) imaging significantly contributes to the benefits from such magnified views. We have been using the HD scope system (Karl Storz SE & Co. KG, Tuttlingen, DE) since the introduction of LCTG in our institution. Advanced energy devices and forceps also contribute to refining the quality of surgery, reducing bleeding, reducing the trauma to organs, and refining the precision of lymphadenectomy. Our sophisticated dissection techniques combined with these advanced developments enable us to perform LCTG with an extremely reduced blood loss compared to previous case–controlled studies (Table 6), leading to earlier recovery of digestive peristalsis.
Robotic gastrectomy could be a future advancement for the treatment of GSC in terms of its visual improvement in the surgical field, which is referred to as robotically enhanced surgical anatomy [34]. The refined anatomical view of robotic gastrectomy could achieve precise movement of forceps without hand tremors, which could increase operative accuracy. In fact, robotic gastrectomy for PGC has decreased the complication rate despite longer operative time and higher cost than laparoscopic gastrectomy [35, 36]. Robotic surgery has already been applied to GSC and reviewed retrospectively, which has shown a lower conversion rate and comparative short-term outcomes to LCTG [37]. We have also introduced robotic surgery to GSC and expect superior results.
We acknowledge some limitations in our study. First, this study had a retrospective design, which could have led to potential selection biases. Therefore, a randomized, controlled study should be completed. Second, due to the low incidence of GSC, the sample size was too small to elucidate the universal results and superiority of LCTG over OCTG for GSC. A multicenter study is necessary to validate our results.