Blair A. Jobe, MDProfessor of Surgery

University of PittsburghPittsburgh, Pennsylvania

ChronologyLaparoscopic distal gastrectomy was introduced

in 1994 by Japanese surgeons (Kitano S).Laparoscopic total gastrectomy was reported in

1995 Reasons for a slow acceptance

Complexity of the procedureOncological adequacy

R0 “en bloc” resection Subtotal gastrectomy (distal cancer) Total gastrectomy (proximal, medial or multifocal cancer)

Appropiate lymph node harvesting Subsequent reconstruction of the alimentary tract

Lymphnodeinvolvement

10-20% N+ in earlygastric cancer

>60% N+ in invasive gastric cancer >T3

20-30% of patient with non earlygastric cancer have microscopicmetastases in the para-aorticnodes (japanasesserieswithextendedlymphadenectomy)

Japaneselymphnode dissection

21

4

3

3

4

4

45

6 D1: 1-6

79 1011118a

D2: D1+7-11

1212

1413D3: D2+12-14

1516

D4: D3+15,16

8p

Second Japanese Classification

1 Right paracardial2 Leftparacardial3 Lessercurvature4sa Short gastricvessels4sb leftgastroepiploic4d right gastrepiploic5 Suprapyloric6 Infrapyloric7 Leftgastricartery8a Common Hepaticarteryant.8p Common hepaticartery Post9 Celiacartery10 Splenichilum11p Proximal splenicartery11d Distal splenicartery12a Hepaticartery12b Along the bile duct12p Behind the portal vein13 Retropancreatichead14v Superior mesentericvein14a Superior mesentericartery15Middle colicvessels16 Around abdominal aorta17 Anteriorpancreatishead18 Inferiormagin of the pancreas

19 Infra diaphragmatic20 Oesophagel hiatus110 paraesophageal in the lower thorax111 Supradiaphragmatic112 Posteriormediastinal

L/M/U

LOWER DISTAL

MIDDLE PART

UPPER

1 1 2 1 1

2 1 M 3 1

3 1 1 1 1

4sa 1 M 3 1

4sb 1 3 1 1

4d 1 1 1 2

5 1 1 1 3

6 1 1 1 3

7 2 2 2 2

8a 2 2 2 2

8b 3 3 3 3

9 2 2 2 2

10 2 M 3 2

11p 2 2 2 2

11d 2 M 3 2

12a 2 2 2 3

12 bp

2 3 3 3

13 3 3 3 M

14v 2 2 3 M

LMU

LD M U

14a M M M M

15 M M M M

16a1 M M M M

16a2, b1

3 3 3 3

16b2 M M M M

17 M M M M

18 M M M M

19 3 M M 3

20 3 M M 3

110 M M M M

111 M M M M

112 M M M M

LymphadenectomyBased on PrimaryTumor Location

D0: no or incomplete dissection of Group 1

D1: Dissection of all the group 1 nodes

D2: Dissection of all the groups 1 and 2 nodes

D3: Dissection of all the groups 1, 2 and 3 nodes

D1 vs D2 lymphnode dissectionin non japaneseseries

DentCape Town Trial

Hong Kong Trial

BonenkampDutch Trial

CuschieriMRC trial

Wu Taiwan Trial

D1 VS D3

1988 1994 92/95/ 99/04 96 / 99 04/06

D1/D2 21 / 20 25/30 380 / 331 200 / 200 110/111

Morbidity 0% / 27% 0% / 46% 25% / 43% 28% / 48% 7.3% /17.1%*

Mortality 0% / 0% 4% / 10% 6.5% / 13%

0% / 0%

Survival 78% / 76%3y

30% / 35%11y

35% / 33%5 y

53.6% / 59.5%*

Extendedlymphadenectomyenhaces more precisestagingSignificantlyhighermorbidityafter D2 dissection withoutimprovement in survival

14 trials (3432 patients)

D1 vs D2 Studies D1 D2

Op mortality 8 3.6% 7.1% .001

Post op morbidity

8 25.5% 44.3% 0.0001

3y survival 4 56.3% 51.3% NS

5y survival 6 48.7% 49.7% NS

D2 vs D3

Op mortality 5 2.3% 2.2% NS

Post op morbidity

5 24.7% 29.6% NSD2 and D3 lymphadenectomyfor gastric cancerdoes not

demonstrate advantages in postoperative survival.

Yang SH. Am J Surg 2009

Extended lymph node dissection for gastric cancer:

Results of the randomized Dutch gastric cancer group trial

Extended lymph node dissection generated no long-term survival benefit

Higher postoperative mortality offsets its long-term effect in survival

M and Mare greatly influenced by the extent of lymph node dissection, pancreatectomy, splenectomy and age

Hartgrink H et al. J Clin Oncol 2004

Extended vs limitedlymphnodedissection -

Meta–analysis2 RCT (MRC and Dutch trials)Possible risks and possible benefits of D2 should

be consideredunproven.D2 dissection is an acceptable procedure in the

hands ofsurgeonsthat can demonstrate lowoperativemortality.

D2 could be considered the preferred treatment for fit patients with intermediate stage (II to III) gastric cancer

D1 dissection should be preferred inpoor surgical candidates and very early cancer.

Cochrane Database 2003

D2 vs extended para-aorticlymphadenectomy

Japaneses RCTJapan Clin

Oncol GroupSano

D2/ Extended 263 / 259

Total gastrectomy 102 / 97

Splenectomy 98 / 93

Pancreatectomy 9 / 13

Mean op time (min) 237 / 300*

Meanbloodloss (ml) 430 / 660*

No of retrievednodes

54 / 74*

Overallmorbidity 20.9% / 28.1%

Re-op 1.0% / 2.7%

Mortality 0.9% / 0.9%

LOS (days) 21 / 24*

Sano T. J Clin Oncol 2004

D2 vs extended para-aorticlymphadenectomyJapaneses RCT: Survival

The 5-year overall survival rate wassame for both groups

Treatmentwith D2 lymphadenectomyplus PAND does not improve survival

Japan Clin Oncol Group

tumor size (cm) 5.5 / 5.5

Upper and middle K 59.4% / 57.7%

P T2b-T4 79% / 80.3%

N+ 70% / 63.1%

R1 0.8% / 0%

MorbidityDiarrhea,lymphorrhea

20.9% 28.1%*9.1% 20%*

5y survival if N- 78.4% / 96.8%

5y survival if N+ 65.2% / 54.9%

Sasako M. New Engl J Med 2008

Meta-analysis Open vs Lap distal gastrectomy

4 RCT including 162 distal gastrectomy (Lap 81 / Op 80)Lapbetterthan Open

Blood loss (357.1 ml vs 258 ml) (-104ml)*Lapworsethan Open

Operative time (186.6 min vs 268.3 min) (+83min)*Lymphnodeharvested ( 32.1 vs 28.5) (-4.3)*

Lap = openHospitalstay (16.1 d vs 12.1d)Mortality (2.5% vs 1.2%)Morbidity rate (35% vs 25%)Tumorrecurrence (12.5% vs 13.4%)Time to oral intake (6 d vs 4.9 d)

Memon MA. SurgEndosc 2008

Improved Quality of Life Outcomes AfterLaparoscopy-Assisted Distal Gastrectomy

for Early Gastric Cancer2003-2005 LADG Open P

82 82

Meanage (y) 56.7 54.5

Mean op time (min) 252 170 0.001

Meanbloodloss (ml) 111 267 0.001

Morbidity 0% 4.8%

Mortality

Lenght of incision (cm)

6.1 19.3 0.05

Meanlymphnode 39 45 0.003

Time to liquiddiet 4.5 4.9 0.0001

Hospitalstay (d) 7.2 8.6 0.0001

Analgesicinfused (ml)

39.4 47.8 0.01Kim YW Ann Surg 2008

Improved Quality of Life Outcomes After

Laparoscopy-Assisted Distal Gastrectomy for Early Gastric Cancer

Pain, appetite loss, and quality of sleep resulted in higher scores in the LADG group compared with the ODG group.

Opengroup had more dysphagia, pain, dietary restriction, and dry mouth at days 7, 30 and 90

LADG better for emotional change, reflux and body image

Kim YW Ann Surg 2008

Laparoscopy-assisted total gastrectomy for gastric cancer: A

multicenterretrospectiveanalysis1485 lap- assistedgastrectomy 1998-2005

Variable Value %

Tumor location (Sup/mid/low)

76/48/5/2 58/37/4/1

Depth of tumor (T1/T2/T3) 90/30/11 69/23/8

Lympnode(N0/N1/N2/N3) 104/21/4/2 79/16/3/2

Mean op time (min) 269

Conversion 1/131

AnastomosisExtra corporealIntra corporealJejunalinterpositionl

11588

8966

Lymphnoderetrieved 34.7

Laparoscopy-assisted total gastrectomy for gastric cancer: A multicenterretrospectiveanalysis

Variable Value %

Time to firstintake (d) 5.8

Postopmorbidity 25 19

Leakage 3 2.3

Post op mortality 0

LOS (d) 11.3

5y cumulativesurvival 89%

5ydisease free survival

94%

Recurrence rate 8 6

Jeong GA . Surgery 2009

ReconstructionSubtotal

gastrectomyTotallylaparoscopic

gastroduodenostomy(Billroth I)

Billroth I throughminilaparotomy

Billroth I with hand port

Roux-en-Y Gastrojejunostomy

Reconstruction after total gastrectomy

Roux-en-Y esophagojejunostomyHand-sewnanastomosis

Laparoscopic Mini-laparotomy

Mechanicalanastomosis Circularstapler

Manuallyloadanvil Transoral (Orivil)

Reconstruction after total gastrectomy

Omori T et al. Am J Surg 2009

Technical Considerations

ConclusionOncologicgastricresectionisfeasibleunderlaparoscopyb

y experienced surgeons and in selectedpatients

Laparoscopic D1 resectionis a reasonableapproach to gastricmalignancy

Asianseries have reported an equivalentsurvivalbetweenlaparoscopic and open gastrectomy

Level 1 trials are lacking in Western countries to demonstratean unquestionableadvantage of the laparoscopicapproach over the open approach