Abstract Laparoscopic gastric cancer surgery includes laparoscopic partial gastrectomy (mainly laparoscopic gastric wedge resection and laparoscopic intragastric mucosal resection) and laparoscopic gastrectomy (laparoscopic distal gastrectomy is commonly used). The former is suitable for early gastric cancer without lymph node metastasis; the latter is suitable for treating patients with early gastric cancer with perigastric lymph nodes (N1) at risk of metastasis, and also extending the indications for surgery to progressive gastric cancer. Laparoscopic gastric cancer surgery is feasible, safe and consistent with the principles of radical tumor surgery. Compared with open gastric cancer surgery, it has similar short-term and long-term outcomes and is superior to the latter in terms of postoperative pain, recovery of gastrointestinal function, length of hospital stay, aesthetics, and quality of life.
With the improvement of gastric cancer diagnostic technology equipment, the detection of early gastric cancer has increased, and the postoperative quality of life has been emphasized due to the low recurrence rate and long survival period after early gastric cancer surgery. In the era of minimally invasive surgery, laparoscopic surgery has the advantages of less trauma, less postoperative pain, faster recovery of gastrointestinal function, shorter hospital stay and less impact on the immune function of the body, etc. These advantages have promoted the exploration of laparoscopic surgery for gastric cancer. Since the first laparoscopic gastrectomy for early gastric cancer in 1991, many surgeons around the world have performed laparoscopic gastrectomy with satisfactory results. 1994, Kitano S et al. reported laparoscopic-assisted Billroth I gastrectomy; 1995, Watson DI et al. reported laparoscopic-assisted Billroth II gastrectomy; 1995, Uyama I et al. reported laparoscopic-assisted Billroth II gastrectomy; and 1995, Uyama I et al. in 1999, Uyama I et al. reported laparoscopic-assisted proximal gastrectomy; in 1999, Uyama I et al. reported laparoscopic total gastrectomy (D2) for progressive gastric cancer; in 2001, Goh PM et al. reported laparoscopic radical gastrectomy (D2) for progressive gastric cancer. This article reviews the current status of the main procedures, indications, and surgical outcomes of laparoscopic gastric cancer surgery.
1.Laparoscopic partial gastrectomy
1.1 Procedure and indications Laparoscopic partial gastrectomy was performed in Japan in 1994 as a minimally invasive treatment for early gastric cancer, and the main procedures include laparoscopic wedge resection (LWR) and intragastric mucosal resection (IGMR) [6], LWR is mainly used for lesions in the antrum, lesser curvature or greater curvature of the stomach, and the indications for surgery include.
1. preoperative diagnosis of intramucosal gastric cancer;
2. elevated lesions <25 mm in diameter;
The lesion is lifted by two methods: lifting with a full suture in the gastric wall and lifting with a T-shaped rod inserted in the stomach, and the lifted lesion is dissected with an Enddcutter or Endo GIA within 1.0 cm from the edge of the lesion together with part of the gastric wall, and the wound is tightly hemostatic and coated with fibrin glue if necessary. Local gastric resection with the assistance of small incisions has also been reported.
The indications for IGMR are similar to those for LWR, mainly for lesions near the posterior gastric wall, cardia or pylorus, and can be divided into 2 types: PTMER and laparoscopic mucosal resection via gastric fistula. pTMER is performed by placing an intestinal clamp through a 5-mm puncture hole in the right upper abdomen to temporarily close the duodenum, flushing gas (CO2) into the stomach via the gastric tube, inserting 3 Trocar into the stomach via the abdominal wall and the gastric wall, following the operating instruments, and performing the procedure in Under the observation of laparoscopy and gastroscopy, the mucosa was removed with an electric knife more than 1.0 cm from the edge of the mass. At the end of the operation, the specimen was removed with the aid of gastroscopic three-jawed forceps, and the mucosa at the edge of the lesion was finally sutured, and each puncture in the gastric wall was sutured laparoscopically one by one. After laparoscopic mucosal resection via gastric fistula, the Buess-type surgical scopes were inserted into the stomach through the gastric fistula, and the central part of the field of view was aligned with the lesion and fixed on the operating table support device, and the lesion was resected according to the PTEMR procedure.
1.2 Efficacy assessment LWR is mainly used in Japan for the treatment of early gastric cancer, but is more commonly used worldwide for submucosal tumors of the gastrointestinal tract (such as smooth muscle tumors and smooth muscle sarcomas); IGMR is not commonly used everywhere because of the difficulty of surgical operation. According to the Japanese Society for Endoscopic Surgery, 260 cases of IGMR and 1428 cases of LWR were performed in Japan between 1991 and 2001, with intraoperative and postoperative complications of 7.1% and 4.6% for IGMR and 4.2% and 6.5% for LWR. Bleeding and impaired gastric emptying were the main complications, with no higher incidence than in open. There are a few reports of short- and long-term outcomes after laparoscopic partial gastrectomy.
Ohgami et al. reported 111 patients with early gastric cancer who underwent local gastrectomy (LWR 93 and IGMR 18), with adequate margins in the horizontal and vertical directions of the surgical specimen, no major complications or surgical deaths, 4 to 8 days of healing and discharge without intermediate open surgery, and 2 patients who recurred within 2 years after the initial operation and had the lesion removed by open surgery at 4 -Shimizu et al. reported the recent results of 24 laparoscopic partial gastrectomies: 20 LWR and 4 IGMR cases, each with 1 intermediate open operation, with operating times of 144±34 min and 298±106 min, bleeding of 56±94 g and 33±58 g, respectively, and hospitalization Hiki reported 29 patients who underwent partial gastrectomy with no recurrence at 46 months follow-up. For early gastric cancer without lymph node metastasis, which meets the appropriate indications for surgery, laparoscopic partial gastrectomy is a curative and minimally invasive procedure.
2.Laparoscopic gastrectomy
2.1 Procedure and indications There are two ways of laparoscopic gastrectomy: total laparoscopic and laparoscopic-assisted gastrectomy. The former surgical operation is done under television laparoscopic surveillance, which is more complicated, with long operation time and higher operation cost. Laparoscopic-assisted gastrectomy means that most of the surgical operations are performed under television laparoscopic surveillance, and then the gastrointestinal tube is dragged out for resection and anastomosis through a small auxiliary incision in the abdominal wall. It includes laparoscopic assisted distal gastrectomy (LADG), proximal gastrectomy and total gastrectomy. LADG is most commonly performed for gastric cancer, and perigastric lymph node dissection (D1), parahepatic lymph node dissection (D1+), and enlarged lymph node dissection (D2) are also feasible. The main operations are as follows: establishing a pneumoperitoneum, which usually requires five poke holes, applying an ultrasonic knife to remove the greater omentum and the transverse colonic mesentery, cutting the right vessel of the gastric omentum at the surface of the pancreas, and removing the subpyloric lymph nodes.
After dissecting the lesser omentum, the left gastric artery is disconnected after double clamping of the blood vessels, the left lymph node of the cardia and the lymph nodes in the upper part of the stomach are cleared downward, the right gastric artery is ligated and the suprapyloric lymph nodes are cleared, and after completely freeing the distal two-thirds of the stomach laparoscopically, a 5-cm incision is made in the middle of the subxiphoid process, the duodenum is transected, the distal two-thirds of the stomach is removed, and the regional lymph nodes are removed along the distal stomach at the same time. The gastrointestinal tract can be reconstructed using a Billroth I gastrojejunostomy, Billroth II gastrojejunostomy or gastrojejunostomy Roux-Y anastomosis. Laparoscopic gastrectomy is primarily indicated for the treatment of patients with early gastric cancer with risk of metastasis to the perigastric lymph nodes (N1). Due to the good results achieved in the treatment of early gastric cancer, some authors have extended the indications for surgery to progressive gastric cancer in recent years. However, it is generally considered unsuitable for patients with advanced gastric cancer. Larger gastric tumors occupying too much intra-abdominal space affect the surgical operation, and the specimens are difficult to be removed, while perigastric lymph node fusion is difficult to be removed.
2.2 Efficacy evaluation In 1997, Goh et al. published the results of a survey of 16 surgeons from 12 countries who performed LADG on 118 cases of benign gastric disease and gastric tumors. 10 surgeons considered LADG superior to conventional open distal gastrectomy (ODG) due to the former’s faster postoperative recovery, less pain and cosmetic results. In 2000, they reported that laparoscopic gastrectomy was significantly better than open distal gastrectomy in terms of postoperative weight loss, swallowing difficulties, cardiac burden and early dumping syndrome. in terms of surgical trauma, recovery of gastrointestinal function, and shorter hospital days.
Recently, Kitano et al. published a randomized controlled trial of laparoscopic gastrectomy in 28 patients with early gastric cancer, in which the authors monitored lung function, visual pain levels at rest, coughing and walking before and on postoperative day 3. The results showed early recovery, pain relief and reduced impact on lung function after LADG. Husche et al.’s study of a randomized clinical trial of 59 patients with progressive gastric cancer showed intraoperative and postoperative advantages of laparoscopic gastrectomy: less intraoperative blood loss, earlier
resumption of oral diet, and earlier hospital discharge.
According to the Japanese Society for Endoscopic Surgery in 2001, 2600 LADG procedures were performed in the past 10 years with a mortality rate of 0. The intraoperative and postoperative complications associated with LADG were 1.4% and 9.75%, respectively. The main intraoperative complication was bleeding and the main postoperative complications were impaired gastric emptying, anastomotic fistula and incisional infection.Adachi et al. reported that the complication rate of LADG was similar to that of ODG.Mochiki et al. reported less intestinal obstruction after LADG than ODG (2% vs. 19%, P=0.003). These results suggest that LADG is a safe procedure.
Despite these encouraging results, there are still many questions as to whether laparoscopic surgery with the assistance of television monitoring can meet the traditional criteria of open tumor resection extent and lymph node dissection.The results of Adachi et al. showed that the length of the proximal margins of LADG and ODG resection specimens were similar (6.2 cm versus 6.0 cm).Weber et al. reported 12 cases of laparoscopic gastrectomy In a study by Husche et al. on lymph node dissection in 59 cases of gastric cancer, the number of lymph nodes was 33.4±17.4 in the open group and 30.0±14.9 in the laparoscopic group, with no difference between the two groups.
There are few reports on long-term outcomes of laparoscopic gastrectomy for gastric cancer. In 1999, Shirasihi reported 40 cases of laparoscopic-assisted gastrectomy and lymph node dissection for early gastric cancer of the sinus and body of the stomach with no postoperative deaths and no recurrence at 21 months of follow-up. In the past decade, Kitano et al. successfully performed LADG on 116 cases of early gastric cancer and all patients survived without recurrence and metastases without poking holes except for one patient who died of cerebral hemorrhage during a mean follow-up period of 45 months.Mochiki et al. randomly divided 60 cases of early gastric cancer into LADG and ODG groups with 5-year survival rates of 98% and 95%, respectively, with no difference between the two groups. Huscher et al. performed laparoscopic radical subtotal gastrectomy on 30 cases of distal stomach, and the overall 5-year and tumor-free survival rates were 58.9% and 57.3%, while the corresponding survival rates for 29 randomized control cases were 55.7% and 54.8%.
3.Summary
Although laparoscopic gastric cancer surgery is still controversial, preliminary clinical trials have shown that it is feasible, safe, and consistent with the principles of radical tumor surgery. Compared with open gastric cancer surgery, it has similar short-term and long-term outcomes and is superior to the latter in terms of postoperative pain, recovery of gastrointestinal function, length of hospital stay, aesthetics, and quality of life. However, laparoscopic gastric cancer surgery requires certain instrumentation and appropriate training in laparoscopic techniques and surgery before performing laparoscopic gastrectomy. We look forward to the results of more prospective, multicenter, randomized clinical trials of laparoscopic gastric cancer surgery.