| Background and objectiveGastric cancer remains one of the most common malignant tumors. Nowadays, Radical surgery is still the mainstay of treatments for gastric cancer. Conventional open gastrectomy is associated with large incision, severe pain, infection or rupture of wound. Laparoscopic gastrectomy with smaller incision, milder postoperative pain, quicker recovery, shorter hospitalization time, has gained the rapid development in the past two decades worldwidely. Due to the technical difficulty of intracorporeal reconstruction of digestive tract, especially the intracorporeal esophagojejunostomy, presently most of laparoscopic gastrectomy is completed with laparoscopic lymphadenectomy and reconstruction of digestive tract through small incision on the upper abdomen, namely laparoscopy-assisted gastrectomy(LATG). If the digestive tract reconstruction can be accomplished laparoscopically, namely totally laparoscopic total gastrectomy (TLTG), the operation vision will be clearer, tension of the anastomotic stoma will be less, minimally invasive advantages will be more remarkable. After Specimens were extracted, the incision is optional with better cosmesis.We completed the first TLTG in2007in our center. Then several intracorporeal esophagojejunostomy methods were tried and a standard protocol of TLTG was established. This study was retrospectively analyzed the clinical data of patients who underwent laparoscopic total gastrectomy in October2007to March2015in our center, and comparison of the outcomes between TLTG and LATG and subgroup analysis between different methods of esophagojejunostomy in TLTG were conducted, to summarize the clinical experience of the TLTG.MethodsPatientsMedical records of consecutive patients underwent laparoscopic total gastrectomy for gastric cancer between October2007and March2015at Sir Run Run Shaw Hospital were collected. Patients with following characteristics were excluded:(1) total gastrectomy with other organ dissection;(2) preoperative TNM stage was Ⅳ;(3) patients with severe comorbidities;(4) patients with neoadjunvant chemotherapy;(5) esophagus was involved;(6) conversion to open surgery;(7) hand assisted laparoscopic total gastrectomy. Surgical techniqueTotal gastrectomy and D2lymphadenotomy were performed according to the Japanese Gastric Cancer guideline. Methods of Roux-en-Y esophagojejunostomy in TLTG was as following:circular stapler-anvil method (Method A), Linear stapler side-to-side method (Method B), Linear stapler delta-shaped method (Method C), Hand-sewn method (Method D). Roux-en-Y esophagojejunostomy in LATG was performed through mini-laparotomy.Measurement①General characteristics, Gender, age, body mass index(BMI), comorbidities, ASA scores et al.②Operative outcomes, Operation time, intraoperative blood loss, transfusion et al.③Oncological characteristics, Tumor size, differentiation, TNM stage, harvested lymph nodes, number of positive lymph nodes, surgical margin et al.④Postoperative outcomes, Time to first flatus, time to first liquid intake, time to first semiliquid intake, postoperative hospital stay, perioperative mortality, postoperative morbidity and treatment.⑤Follow-up, Follow-up was continued with clinic or phone call, which including follow up time, recurrence and time to death.StatisticAll the data were reviewed and statistically analyzed using SPSS18.0. Significance was defined as P<0.05.ResultsGeneral characteristicsThe present study included103patients underwent TLTG, with67males and36females. The average age was61.3±10.9years old and the average BMI was22.4±3.3kg/m2.43patients had comorbidities.53patients got1ASA score,45patients got2scores,5patients got3.125patients underwent LATG, with75males and50females. The average age was59.7±10.5years old and the average BMI was21.7±3.2kg/m2.37patients had comorbiditie.62patients got1ASA score,57patients got2scores,6patients got3. Compared with LATG, there were no significant differences regarding to characteristics mentioned above.Operative outcomes and postoperative outcomesThe mean operation time of TLTG group was276.3±51.1min. The mean intraoperative blood loss of TLTG group was71.1±45.9ml. The mean number of harvested lymph nodes was34.4±13.9. The mean time to first flatus was3.7±1.0d, the mean time to first liquid intake was4.9±1.8d, the mean time to first semiliquid intake7.0±2.4d, the mean postoperative hospital stay was10.3±4.1d. The postoperative morbidity was13.6%. The mean operation time of LATG group was247.5±66.2min. The mean intraoperative blood loss of LATG group was147.1±84.9ml. The mean number of harvested lymph nodes was35.1±13.2. The mean time to first flatus was3.9±1.1d, the mean time to first liquid intake was5.1±1.4d, the mean time to first semiliquid intake7.9±4.0d, the mean postoperative hospital stay was11.3±4.9d. The postoperative morbidity was19.2%. There was no perioperation death in both groups.There were no significant differences between two groups regarding to the operation time, number of harvested lymph nodes, postoperative morbidity. TLTG group had less intraoperative blood loss, milder postoperative pain and faster postoperative recovery.Outcomes of different esophagojejunostomy methodsThere were18patients underwent method A, the mean anastomotic time was57.5±18.5min. One patient had anastomotic stricture and one patients had anastomotic leakage.22patients underwent method B, the mean anastomotic time was40.0±11.2min, two patients had anastomotic stricture and one patients had anastomotic bleeding.10patients underwent method C, the mean anastomotic time was39.0±3.9min.53patients underwent method D, the mean anastomotic time was56.8±19.3min.ConclusionTLTG is a feasible and safe approach. Our present study indicated that TLTG had less blood loss,less surgical trauma, faster postoperative recovery. Hand-sewn method is a promising technique due to its characteristics such as safer and economic. |
PDF Full Text Request