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BACKGROUND: A previous report confirmed the safety of laparoscopy-assisted total and proximal gastrectomies (LATG and LAPG) (JCOG1401). This report demonstrates the 5-year relapse-free survival (RFS) and overall survival (OS) after long-term follow-up to confirm the efficacy of these surgical methods as key secondary endpoints for cStage I gastric cancer. METHODS: This study enrolled patients who had histologically proven gastric adenocarcinoma and were diagnosed with clinical T1N0, T1N(+), or T2N0 tumors according to the 14th edition of the Japanese Classification of Gastric Carcinoma (3rd English edition). RESULTS: Between April 2015 and February 2017, 246 patients were enrolled, although one patient was excluded because of misregistration. Meticulous follow-up was continued for > 5 years for each patient, and the data were analyzed in March 2022. The 5-year RFS was 90.0% (95% confidence interval [CI] 85.5-93.2%), and the 5-year OS was 91.2% (95% CI 86.9-94.2%) in all enrolled patients. Grade 3 or 4 late postoperative complications were detected in 12.7% of patients. CONCLUSIONS: This single-arm study showed that the long-term outcomes of LATG/LAPG for cStage I gastric cancer were acceptable, which is considered one of the standard treatments when performed by experienced surgeons. Trail registration UMIN000017155 ( http://www.umin.ac.jp/ctr/ ).

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BACKGROUND: Laparoscopic total gastrectomy for early proximal gastric cancer is widely performed. Recently, the number of laparoscopic proximal gastrectomies performed, a surgery limited to early proximal gastric cancer, has gradually increased. However, evidence for the long-term outcomes of laparoscopic total gastrectomy and laparoscopic proximal gastrectomy is insufficient. Therefore, this study aimed to clarify and compare the long-term outcomes of laparoscopic total gastrectomy and laparoscopic proximal gastrectomy with novel valvuloplastic esophagogastrostomy for treatment of clinical stage I proximal gastric cancer. METHODS: This study included 111 patients who underwent laparoscopic total gastrectomy or laparoscopic proximal gastrectomy for the treatment of upper third clinical stage I gastric cancer between April 2004 and December 2017. After adjusting for propensity score matching analysis, we compared the postoperative complications, nutritional status, and long-term outcomes between the two groups. RESULTS: After matching the inclusion criteria, 56 patients (28 in each group) were enrolled. No significant differences were noted in the postoperative complications between the two groups. While laparoscopic proximal gastrectomy was associated with lower albumin levels, lower body weight loss was seen by 1 year after surgery and higher hemoglobin levels by 1, 2, and 3 years after surgery. No significant differences were observed in the 3-year overall survival and 3-year recurrence-free survival between the laparoscopic total gastrectomy and laparoscopic proximal gastrectomy groups (P = 0.74 and 0.72, respectively). CONCLUSION: Laparoscopic proximal gastrectomy and laparoscopic total gastrectomy for patients with upper third clinical stage I gastric cancer are feasible as regards its safety and outcomes.

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BACKGROUND: This study aimed to evaluate the surgical outcome and quality of life (QoL) of totally laparoscopic total gastrectomy (TLTG) compared with laparoscopy-assisted total gastrectomy (LATG) in patients with clinical stage I gastric cancer. METHODS: From 2012 to 2018, EGC patients who underwent TLTG (n = 223), including the first case with intracorporeal hemi-double stapling, were matched to those who underwent LATG (n = 114) with extracorporeal circular stapling, using 2:1 propensity score matching (PSM). Prospectively collected morbidity was compared between the TLTG and LATG groups in conjunction with the learning curve. The European Organization for Research and Treatment of Cancer (EORTC) QoL questionnaires QLQ-C30, STO22, and OG25 were prospectively surveyed during postoperative 1 year for patient subgroups. RESULTS: After PSM, grade I pulmonary complication rate was lower in the TLTG group (n = 213) than in the LATG group (n = 111) (0.5% vs. 5.4%, P = 0.007). Other complications were not different between the groups. The learning curve of TLTG was overcome at the 26th case in terms of the comprehensive complication index. The TLTG group after learning curve showed lower grade I pulmonary complication rate than the matched LATG group (0.5% vs. 4.7%, P = 0.024). Regarding postoperative QoL, the TLTG group (n = 63) revealed less dysphagia (P = 0.028), pain (P = 0.028), eating restriction (P = 0.006), eating (P = 0.004), odynophagia (P = 0.023) than the LATG group (n = 21). Multivariate analyses for each QoL item demonstrated that TLTG was the only common independent factor for better QoL. CONCLUSIONS: TLTG reduced grade I pulmonary complications and provided better QoL in dysphagia, pain, eating, odynophagia than LATG for patients with clinical stage I gastric cancer.

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BACKGROUND/AIM: Laparoscopy-assisted total gastrectomy (LATG) for gastric cancer may prevent the loss of body weight or lean body mass after surgery due to its reduced surgical stress compared with open total gastrectomy (OTG). PATIENTS AND METHODS: A total of 303 patients were examined in this study. All patients received the same perioperative care via fast-track surgery. The body weight and composition were evaluated using a bioelectrical impedance analyzer within 1 week before and at 1 week, 1 month, and 3 months after surgery. RESULTS: Two hundred and eight patients received OTG, and 95 received LATG. Although the clinical T factor and N factor were significantly different between these two groups, other clinical factors were similar. The respective body weight loss (1 week/1 month/3 months) was -4.7%/-8.0%/-11.9% in the OTG group and -4.7%/-8.2%/-11.6% in the LATG group, that were not significantly different between the two groups at any time point of measurement (p=0.698/0.528/0.534, respectively). The respective lean body mass loss (1 week/1 month/3 months) was -4.2%/-6.4%/-7.4% in the OTG group and -4.0%/-5.8%/-6.2% in the LATG group, that were not significantly different between the groups (p=0.503/0.588/0.946, respectively). CONCLUSION: The body composition changes were similar between the OTG and LATG groups using the same perioperative care of fast-track surgery. Adopting a laparoscopic approach would not help in reducing loss of body weight or lean body mass after gastric cancer surgery.

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BACKGROUND/AIMS: The study aimed to clarify the risk factors for anastomotic leakage after laparoscopy-assisted total gastrectomy (LATG) for gastric cancer. METHODS: In this study, we enrolled 131 patients with preoperatively diagnosed early gastric cancer who underwent LATG by a single surgeon between June 2006 and February 2014 at the Department of Surgery, Gastroenterological Center, Yokohama City University. Risk factors for anastomotic leakage (esophagojejunostomy) after LATG were retrospectively evaluated by univariate and multivariate analyses. RESULTS: Anastomotic leakage of the esophagojejunostomy was observed in 13 (9.9%) of 131 patients. Univariate analysis of risk factors for anastomotic leakage revealed that the prognostic nutritional index (PNI) is a risk factor for anastomotic leakage (<55, 11 of 63 vs. ≥55, 2 of 55; p = 0.039). Multivariate analysis revealed that PNI is an independent risk factor for anastomotic leakage (OR 0.208; 95% CI 0.044-0.981; p = 0.047). CONCLUSION: Gastric cancer patients with a low PNI have a higher risk for anastomotic leakage after LATG. The results of this study must be confirmed by a study with a large cohort of patients receiving LATG reconstructed using the same method by experienced surgeons in multiple institutions.

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BACKGROUND: Few studies have been designed to evaluate the short- and long-term outcomes of laparoscopy-assisted total gastrectomy (LATG), and a retrospective study of a large patient cohort is valuable before conducting randomized controlled clinical trials. RESULTS: Among all patients, age, tumor location, histologic type, pT stage, pN stage and pTNM stage significantly differed between the LATG group and OTG group. After the propensity score matching, the clinicopathological characteristics did not significantly differ between groups. The operation time, estimated blood loss, time to first flatus and the number of retrieved lymph nodes (P < 0.05) were better in the LATG group than the OTG group. Morbidity and mortality were lower in the LATG group than the OTG group (P < 0.05) for pre-matched patients. However, significant intergroup differences in morbidity were not identified after propensity matching. Although overall survival did not significantly differ between groups for the pre-matched patients, the 3-year cumulative survival rates were significantly lower in the LATG group (89.9%) than the OTG group (97.7%) for patients with stage I disease (P = 0.028). After propensity score matching, the analysis of the cumulative survival curve did not show a significant difference for any cancer stage. MATERIALS AND METHODS: We prospectively collected data from 1096 patients who underwent total gastrectomy for gastric cancer. Propensity score matching was applied to compare the covariates between the LATG group and the open total gastrectomy (OTG) group. Operative outcomes and long-term outcomes were compared between the two groups. CONCLUSIONS: Implementation of LATG for gastric cancer is a safe, reliable and minimally invasive procedure with long-term outcomes similar to those of OTG. Further randomized controlled clinical trials can be conducted to provide valuable evidence of the safety and efficacy of LATG in treating gastric cancer.

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A 54-year-old man was admitted to our hospital with severe nausea, vomiting and abdominal pain. He had had laparoscopy-assisted total gastrectomy with Roux-en-Y reconstruction and tube jejunostomy for gastric cancer 2 years earlier. Abdominal CT revealed that the duodenum and upper jejunum were markedly dilated and that the dilated jejunum had collapsed at the jejunostomy site. Emergency laparoscopic surgery with three ports was performed for jejunostomy-related ileus. Abdominal adhesion was very small, and the Roux-en-Y limb was rotated counterclockwise at the jejunostomy site. A magnified laparoscopic view showed that the site of peritoneopexy was the axis of rotation. After the axis was dissected with a Harmonic scalpel, the rotation was released immediately. The patient's postoperative course was uneventful and he was discharged 4 days after the operation. Because the axis of rotation was identified easily by laparoscope, laparoscopic surgery was a safe and useful technique for a patient with jejunostomy-related ileus.

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Hypertrophic hypersecretory gastropathy with protein loss (HHGP) is a rare form of acquired gastropathy characterized by giant gastric rugal folds and hypoalbuminemia. It is often misdiagnosed as Ménétrier's disease. We report the case of a 45-year-old man with HHGP who presented with nausea and anorexia. The patient had no underlying disease and was not on medication. Esophagogastroduodenoscopy and CT showed a thickening of the gastric folds in the stomach. As cancer cells were not detected on endoscopic biopsies, the patient was diagnosed with Ménétrier's disease. He was managed with a high-protein diet and annual follow-up by esophagogastroduodenoscopy. Five years after the diagnosis, the patient underwent laparoscopy-assisted total gastrectomy for refractory abdominal pain, diarrhea, and protein loss. A pathological diagnosis of HHGP was made and he was discharged without any surgical complications. The patient was relieved of anorexia, abdominal pain, and diarrhea. Laparoscopy-assisted total gastrectomy could be regarded as a treatment option for HHGP.

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AIM: To investigate the feasibility of laparoscopy-assisted total gastrectomy (LATG) using trans-orally inserted anvil (OrVil™) in terms of operative characteristics and short term outcomes. RESULTS: Characteristics of 27 patients with gastric cancer who underwent LATG from October 2009 to October 2012 in the Foshan Affiliated Hospital of South Medical University were retrospectively reviewed. Among these patients, six were reconstructed by mini-laparotomy and 21 by OrVil™. The clinicopathological characteristics, total operation time, total blood loss, abdominal incision and complications of anastomosis including stenosis and leakage, were compared between the groups undergoing LATG with OrVil™ and the group undergoing mini-laparotomy. RESULTS: The operations were successfully performed on all the patients without intraoperative complications or conversion to open surgery. Two (10%) patients received palliative procedure under laparoscope who were prepared for LATG preoperatively. One case had hepatic metastatic carcinoma and 1 case had tumor recurrence near the anastomosis 8 mo after surgery. The mean follow-up duration was 10 mo (range, 2-24 mo). Operation time was significantly reduced by the use of OrVil™ (198.42 ± 30.28 min vs 240.83 ± 8.23 min). The postoperative course with regard to occurrence of stenosis and leakage was not different between the two groups. There were no significant differences in estimated blood loss. The upper abdominal incision was smaller in OrVil™ group than in mini-laparotomy group (4.31 ± 0.45 cm vs 6.43 ± 0.38 cm). CONCLUSION: LATG using OrVil™ is a technically feasible surgical procedure with sufficient lymph node dissection, less operation time and acceptable morbidity.

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Juvenile polyposis syndrome (JPS) is a dominantly inherited disorder characterized by the development of numerous juvenile polyps (JPs) of the gastrointestinal tract, and associated with a mutation of the SMAD4 or BMPR1A gene. Here, we report a mother-daughter case of familial JPS. A 29-year-old female patient with severe iron deficiency anemia and hypoproteinemia had numerous polyps in the stomach and a few polyps in the ileum and colon that were detected endoscopically. Biopsy specimens from the gastric polyps were diagnosed as JPs. The patient underwent a laparoscopy-assisted total gastrectomy, and her anemia and hypoproteinemia improved. Her mother also had multiple JPs in the stomach, duodenum, jejunum, and colon. We then diagnosed them as having familial JPS. Moreover, germline mutation analysis of the 2 patients presented a novel pathogenic SMAD4 variant.

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PURPOSE: The aim of this study was to compare end-to-side with side-to-side esophagojejunostomy after laparoscopy-assisted total gastrectomy (LATG) for gastric cancer in terms of complications. METHODS: One hundred and fourteen patients who underwent laparoscopy-assisted total gastrectomy for gastric cancer with curative intent from June 2003 to February 2010 at Seoul National University Bundang Hospital were retrospectively reviewed. Comparative analysis of short term outcomes including complications was performed to compare the end-to-side esophagojejunostomy (EJ) and side-to-side EJ groups. RESULTS: Overall morbidity and mortality rates after LATG were 17.5% (20 patients) and 0%, respectively. Comparing the end-to-side EJ group (93 patients) with the side-to-side EJ group (21 patients), there was no significant difference in operating time (242.3 versus 250.7 minutes), estimated blood loss (176.6 versus 133.3 ml), time to first flatus (3.8 versus 4.0 days), time to first soft diet (5.3 versus 5.7 days), postoperative morbidity (15.1% versus 28.6%), and mortality. However, there was a difference in postoperative hospital stay (9.0 versus 12.9 days, p=0.045). Also, the EJ leakage rate of the side-to side EJ group was higher than that of end-to-side EJ group (14.3%, 3 patients, versus 2.2%, 2 patients; p=0.043). CONCLUSION: End-to-side EJ can be recommended after LATG because the EJ leakage rate after end-to-side EJ was lower than that after side-to-side EJ.

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PURPOSE: The aim of this study was to compare the short-term operative outcomes of laparoscopy-assisted total gastrectomy (LATG) with those of open total gastrectomy (OTG) for patients suffering with advanced upper gastric cancer. MATERIALS AND METHODS: Of the 47 patients who underwent LATG with D1+beta or D2 lymphadenectomy from July 2004 to March 2008, 29 patients with pathologically proven advanced gastric cancer were compared with 35 patients who underwent conventional OTG during the same time period. The comparison was based on the clinicopathological characteristics, the surgical outcome, the follow-up survival and tumor recurrence. RESULTS: The patients' age, gender and body mass index were similar between the two groups. However, there were statistically differences in tumor size (9.2+/-3.9 vs 6.1+/-3.6 cm, P=0.002) and the proximal resected margin (2.1+/-2.0 vs 3.6+/-2.1 cm P=0.004). There was no significant difference in most of the peri- and post-operative courses such as the time to first flatus, the time to starting a solid diet and the length of the hospital stay, except for a longer operating time (289.0 vs. 361.3 minutes, P<0.001) in the LATG group. The complication rate was higher in the LATG group (13.8%) than that in the OTG group (5.7%). The mean overall survival and disease free survival times were 32 and 31 months, and 24 and 28 months, respectively, with an average 18.8 months follow-up duration. The main recurrent sites were peritoneum and lymph node in both groups. CONCLUSION: The early results of the current study suggest that LATG for AGC is technically feasible and it does not show any inferiorities of the postoperative outcomes as compared to those of conventional open total gastrectomy.

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PURPOSE: The purpose of this study was to compare the short-term clinical outcomes of laparoscopy-assisted total gastrectomy (LATG) with conventional open total gastrectomy (OTG) for treating proximal early gastric cancer and to determine the usefulness of the LATG procedure. METHODS: The records of 21 patients who underwent LATG for proximal early gastric cancer from January 2004 to August 2006 were retrospectively reviewed and compared with those records of 20 patients who underwent OTG during the same period. RESULTS: The patient characteristics, including gender, age, body mass index and comorbidities, were similar between the two groups. Combined resections were more frequently done in the OTG group than in the LATG group. The blood loss in the LATG group was significantly less than that in the OTG group. The operating time, time to first flatus and initial oral intake and the postoperative hospital stay were significantly shorter in the LATG group. The number of resected lymph nodes, lymph node metastasis, histologic type, TNM stage, complications, leukocyte counts and serum lactic acid levels were not significantly different between the two groups. CONCLUSION: LATG is a technically safe and feasible procedure for treating proximal early gastric cancer. Prospective multi-center trials are necessary to establish LATG as the standard treatment for proximal early gastric cancer.

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We report our experience with a case of performing laparoscopy-assisted total gastrectomy along with pancreas-preserving splenectomy for treating early gastric cancer. Laparoscopy-assisted total gastrectomy was planned for a 62-year-old male patient with a double early gastric cancer located in the upper and lower third of the stomach. Five trocars were placed and we used a harmonic scalpel to dissect the greater curvature. Enlarged splenic hilar lymph node was encountered and they were proved to be metastasis by frozen section biopsy. We then performed total gastrectomy with pancreas-preserving splenectomy for the purpose of completely dissecting the lymph nodes along the splenic artery and splenic hilum. We created a 4 cm sized longitudinal mini-laparotomy below the xiphoid process to remove the specimen, and anastomosis was done via the Roux-en-Y method. The patient was discharged on the 9th postoperative days after an uneventful recovery. Our experience shows that laparoscopy-assisted total gastrectomy with pancreas-preserving splenectomy is a relatively safe procedure for treating upper third early gastric cancer with metastatic splenic hilar lymph nodes.

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PURPOSE: The number of laparoscopy assisted distal gastrectomies (LADG) is gradually increasing for the treatment of early gastric cancer (EGC) patients as a surgical modality for improving quality of life. However, there are few reports on laparoscopy-assisted total gastrectomy (LATG), mainly because this procedure is performed relatively infrequently, and the procedure is more complicated than LADG. This study was performed to evaluate the technical feasibility, safety, and surgical results of LATG with lymphadenectomy through a review of our experience. MATERIALS AND METHODS: From July 2003 to June 2007, 77 LATG with Roux-en-Y esophagojejunostomy were performed for patients with a preoperative diagnosis of EGC. The clinicopathological features and surgical outcomes were analyzed. RESULTS: There were 49 males and 28 females in the study with a mean age of 61 years (range 30~85 years). The mean operation time was 210 minutes (range 100~400 minutes) and the operation time was gradually decreased as the case numbers increased. There were 13 operative morbidities (16.9%) and no operative mortalities. The restoration of bowel motility was noted at 3.2 postoperative days; a soft diet was started at 4.4 postoperative days and the duration of hospital stay was 10 days. There were 20 mucosal lesions, 32 submucosal lesions, 15 proper muscle lesions, 7 subserosal lesions and 3 serosal lesions. A total of 20 patients were treated by D2 lymph node dissection, 55 patients were treated by D1+beta lymph node dissection, and two patients were treated by D1 + alpha lymph node dissection. The mean number of retrieved lymph nodes was 42 (range 11~86). Lymph node metastases were noted in 12 patients CONCLUSION: This study indicated LATG could be applied safely and effectively for patients with EGC. However, a prospective study comparing laparoscopy-assisted versus open gastrectomy for short-term and long-term surgical outcome is needed.

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