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1.  Case-matched comparison of laparoscopy-assisted and open distal gastrectomy for gastric cancer 
AIM: To compare short- and long-term outcomes of laparoscopy-assisted and open distal gastrectomy for gastric cancer.
METHODS: A retrospective study was performed by comparing the outcomes of 54 patients who underwent laparoscopy-assisted distal gastrectomy (LADG) with those of 54 patients who underwent open distal gastrectomy (ODG) between October 2004 and October 2007. The patients’ demographic data (age and gender), date of surgery, extent of lymphadenectomy, and differentiation and tumor-node-metastasis stage of the tumor were examined. The operative time, intraoperative blood loss, postoperative recovery, complications, pathological findings, and follow-up data were compared between the two groups.
RESULTS: The mean operative time was significantly longer in the LADG group than in the ODG group (259.3 ± 46.2 min vs 199.8 ± 40.85 min; P < 0.05), whereas intraoperative blood loss and postoperative complications were significantly lower (160.2 ± 85.9 mL vs 257.8 ± 151.0 mL; 13.0% vs 24.1%, respectively, P < 0.05). In addition, the time to first flatus, time to initiate oral intake, and postoperative hospital stay were significantly shorter in the LADG group than in the ODG group (3.9 ± 1.4 d vs 4.4 ± 1.5 d; 4.6 ± 1.2 d vs 5.6 ± 2.1 d; and 9.5 ± 2.7 d vs 11.1 ± 4.1 d, respectively; P < 0.05). There was no significant difference between the LADG group and ODG group with regard to the number of harvested lymph nodes. The median follow-up was 60 mo (range, 5-97 mo). The 1-, 3-, and 5-year disease-free survival rates were 94.3%, 90.2%, and 76.7%, respectively, in the LADG group and 89.5%, 84.7%, and 82.3%, respectively, in the ODG group. The 1-, 3-, and 5-year overall survival rates were 98.0%, 91.9%, and 81.1%, respectively, in the LADG group and 91.5%, 86.9%, and 82.1%, respectively, in the ODG group. There was no significant difference between the two groups with regard to the survival rate.
CONCLUSION: LADG is suitable and minimally invasive for treating distal gastric cancer and can achieve similar long-term results to ODG.
doi:10.3748/wjg.v19.i23.3672
PMCID: PMC3691043  PMID: 23801871
Stomach neoplasms; Gastrectomy; Laparoscopy; Survival; Case matched study
2.  Comparison of Short-Term Postoperative Outcomes in Totally Laparoscopic Distal Gastrectomy Versus Laparoscopy-Assisted Distal Gastrectomy 
Journal of Gastric Cancer  2014;14(2):105-110.
Purpose
The advantages of totally laparoscopic surgery in early gastric cancer (EGC) are unproven, and some concerns remain regarding the oncologic safety and technical difficulty. This study aimed to evaluate the technical feasibility and clinical benefits of totally laparoscopic distal gastrectomy (TLDG) for the treatment of gastric cancer compared with laparoscopy-assisted distal gastrectomy (LADG).
Materials and Methods
A retrospective review of 211 patients who underwent either TLDG (n=134; 63.5%) or LADG (n=77; 36.5%) for EGC between April 2005 and October 2013 was performed. Clinicopathologic features and surgical outcomes were analyzed and compared between the groups.
Results
The operative time in the TLDG group was significantly shorter than that in the LADG group (193 [range, 160~230] vs. 215 minutes [range, 170~255]) (P=0.021). The amount of blood loss during TLDG was estimated at 200 ml (range, 100~350 ml), which was significantly less than that during LADG, which was estimated at 400 ml (range, 400~700 ml) (P<0.001). The hospital stay in the TLDG group was shorter than that in the LADG group (7 vs. 8 days, P<0.001). One patient from each group underwent laparotomic conversion. Two patients in the TLDG group required reoperation: one for hemostasis after intraabdominal bleeding and 1 for repair of wound dehiscence at the umbilical port site.
Conclusions
TLDG for distal EGC is a technically feasible and safe procedure when performed by a surgeon with sufficient experience in laparoscopic gastrectomy and might provide the benefits of reduced operating time and intraoperative blood lossand shorter convalescence compared with LADG.
doi:10.5230/jgc.2014.14.2.105
PMCID: PMC4105374  PMID: 25061537
Stomach neoplasms; Laparoscopy; Gastrectomy
3.  Comparative Study of Laparoscopy-Assisted versus Open Subtotal Gastrectomy for pT2 Gastric Cancer 
Yonsei Medical Journal  2012;53(5):952-959.
Purpose
Laparoscopy-assisted distal gastrectomy (LADG) is a widely accepted surgery for early gastric cancer. However, its use in advanced gastric cancer has rarely been studied. The aim of this study is to investigate the feasibility and survival outcomes of LADG for pT2 gastric cancer.
Materials and Methods
Between January 2004 and December 2009, we evaluated 67 and 52 patients who underwent open distal gastrectomy (ODG) and LADG, respectively, with diagnosis of pT2 gastric cancer. The clinicopathological characteristics, postoperative outcomes, and survival were retrospectively compared between the two groups.
Results
There were statistically significant differences in the proximal margin of the clinicopathological parameters. The operation time was significantly longer in LADG than in ODG (207.7 vs. 159.9 minutes). There were 6 (9.0%) and 5 (9.6%) complications in ODG and LADG, respectively. During follow-up periods, tumor recurrence occurred in 7 (10.4%) patients of the ODG and in 4 (7.7%) patients of the LADG group. The 5-year survival rate of ODG and LADG was 88.6% and 91.3% (p=0.613), respectively. In view of lymph node involvement, 5-year survival rates were 96.0% in ODG versus 97.0% in LADG for patients with negative nodal metastasis (p=0.968) and 80.9% in ODG versus 78.7% in LADG for those with positive nodal metastasis (p=0.868).
Conclusion
Although prospective study is necessary to compare LADG with open gastrectomy for the treatment of advanced gastric cancer, laparoscopy-assisted distal gastrectomy might be considered as an alternative treatment for some pT2 gastric cancer.
doi:10.3349/ymj.2012.53.5.952
PMCID: PMC3423848  PMID: 22869478
Laparoscopy; pT2 gastric cancer; subtotal gastrectomy
4.  Comparison of Learning Curves and Clinical Outcomes between Laparoscopy-assisted Distal Gastrectomy and Open Distal Gastrectomy 
Journal of Gastric Cancer  2010;10(4):247-253.
Purpose
Most stomach surgeons have been educated sufficiently in conventional open distal gastrectomy (ODG) but insufficiently in laparoscopy-assisted distal gastrectomy (LADG). We compared learning curves and clinical outcomes between ODG and LADG by a single surgeon who had sufficient education of ODG and insufficient education of LADG.
Materials and Methods
ODG (90 patients, January through September, 2004) and LADG groups (90 patients, June 2006 to June 2007) were compared. The learning curve was assessed with the mean number of retrieved lymph nodes, operation time, and postoperative morbidity/mortality.
Results
Mean operation time was 168.3 minutes for ODG and 183.6 minutes for LADG. The mean number of retrieved lymph nodes was 37.9. Up to about the 20th to 25th cases, the slope decrease in the learning curve for LADG was more apparent than for ODG, although they both reached plateaus after the 50th cases. The mean number of retrieved lymph nodes reached the overall mean after the 30th and 40th cases for ODG and LADG, respectively. For ODG, complications were evenly distributed throughout the subgroups, whereas for LADG, complications occurred in 10 (33.3%) of the first 30 cases.
Conclusions
Compared with conventional ODG, LADG is feasible, in particular for a surgeon who has had much experience with conventional ODG, although LADG required more operative time, slightly more time to get adequately retrieved lymph nodes and more complications. However, there were more minor problems in the first 30 LADG than ODG cases. The unfavorable results for LADG can be overcome easily through an adequate training program for LADG.
doi:10.5230/jgc.2010.10.4.247
PMCID: PMC3204502  PMID: 22076193
Laparoscopic; Gastrectomy; Learning curve
5.  Benefits of intracorporeal gastrointestinal anastomosis following laparoscopic distal gastrectomy 
Background
Laparoscopic gastrectomy has recently been gaining popularity as a treatment for cancer; however, little is known about the benefits of intracorporeal (IC) gastrointestinal anastomosis with pure laparoscopic distal gastrectomy (LDG) compared with extracorporeal (EC) anastomosis with laparoscopy-assisted distal gastrectomy (LADG).
Methods
Between June 2000 and December 2011, we assessed 449 consecutive patients with early-stage gastric cancer who underwent LDG. The patients were classified into three groups according to the method of reconstruction LADG followed by EC hand-sewn anastomosis (LADG + EC) (n = 73), using any of three anastomosis methods (Billroth-I (B-I), Billroth-II (B-II) or Roux-en-Y (R-Y); LDG followed by IC B-I anastomosis (LDG + B-I) (n = 248); or LDG followed by IC R-Y anastomosis (LDG + R-Y) (n = 128)). The analyzed parameters included patient and tumor characteristics, operation details, and post-operative outcomes.
Results
The tumor location was significantly more proximal in the LDG + R-Y group than in the LDG + B-I group (P < 0.01). Mean operation time, intra-operative blood loss, and the length of post-operative hospital stay were all shortest in the LDG + B-I group (P < 0.05). Regarding post-operative morbidities, anastomosis-related complications occurred significantly less frequently in with the LDG + B-I group than in the LADG + EC group (P < 0.01), whereas there were no differences in the other parameters of patients’ characteristics.
Conclusions
Intracorporeal mechanical anastomosis by either the B-I or R-Y method following LDG has several advantages over at the LADG + EC, including small wound size, reduced invasiveness, and safe anastomosis. Although additional randomized control studies are warranted to confirm these findings, we consider that pure LDG is a useful technique for patients with early gastric cancer.
doi:10.1186/1477-7819-10-267
PMCID: PMC3546847  PMID: 23232031
Laparoscopic distal gastrectomy; Intracorporeal anastomosis; Extracorporeal anastomosis; Billroth I; Roux-en-Y
6.  Meta-analysis of short-term outcomes after laparoscopy-assisted distal gastrectomy 
AIM: To elucidate the current status of laparoscopy-assisted distal gastrectomy (LADG) with regard to its short-term outcomes by comparing it with conventional open distal gastrectomy (CODG).
METHODS: Original articles published from January 1991 to August 2006 were searched in the MEDLINE, EMBASE, and Cochrane Controlled Trials Register. Clinical appraisal and data extraction were conducted independently by 2 reviewers. A meta-analysis was performed using a random effects model.
RESULTS: Outcomes of 1611 procedures from 4 randomized controlled trials and 12 retrospective studies were analyzed. Compared to CODG, LADG was a longer procedure (weighted mean difference [WMD] 54.3; 95% confidence interval [CI] 38.8 to 69.8; P < 0.001), but was associated with a lower associated morbidity (odds ratio [OR] 0.54; 95% CI 0.37 to 0.77; P < 0.001); this was most significant for postoperative ileus (OR 0.27; 95% CI 0.09 to 0.84; P = 0.02). There was no significant difference between the two groups in anastomotic, pulmonary, and wound complications and mortality. Duration from surgery to first passage of flatus was faster (WMD -0.68; 95% CI -0.85 to -0.50; P < 0.001) and the frequency of additional analgesic requirement (WMD -1.36; 95% CI -2.44 to -0.28; P = 0.01), and duration of hospital stay (WMD -5.51; 95% CI -7.61 to -3.42; P < 0.001) were significantly lower after LADG. However, a significantly higher number of lymph nodes were dissected by CODG (WMD -4.35; 95% CI -5.73 to -2.98; P < 0.001).
CONCLUSION: LADG for early gastric cancer is associated with a lower morbidity, less pain, faster bowel function recovery, and shorter hospital stay.
doi:10.3748/wjg.v12.i47.7676
PMCID: PMC4088052  PMID: 17171799
Laparoscopic gastrectomy; Gastric cancer; Postoperative complications; Mortality; Lymphadenectomy; Meta-analysis
7.  Laparoscopy-Assisted Distal Gastrectomy in a Patient With Situs Inversus Totalis 
Introduction:
We report on a patient with situs inversus totalis who underwent laparoscopic-assisted distal gastrectomy (LADG) involving standard lymph node dissection (LND) for early gastric cancer.
Case Description:
A 42-y-old man presented at the Department of Internal Medicine in our hospital with the diagnosis of early gastric cancer detected elsewhere by upper endoscopy. Endoscopic submucosal dissection for this early gastric cancer was performed at our hospital. Histopathological examination of the resected specimen yielded the diagnosis of type 0-IIc, T1b1(SM), ly (+), v (−), UL (−), HM0, VM0, R0, according to the Japanese Classification of Gastric Carcinoma. Additional surgery was deemed necessary, and he was referred to our department. Preoperative computed tomography showed no liver or lung metastasis. The preoperative diagnosis was cStage IA (pT1b1, cN0, cH0, cP0, and cM0). Standard LADG with LND (D1+No.7, 8a, 9) was performed successfully. Histological examination disclosed stage IB (pT1b1, pN1, sH0, sP0, and sM0). The patient was discharged on postoperative day 14 after an uneventful postoperative course. Eighteen months after the operation, he is doing well without recurrent gastric cancer.
Conclusion:
Laparoscopic surgery for gastric cancer with SIT should be considered a feasible, safe, and curative procedure.
doi:10.4293/108680813X13693422521953
PMCID: PMC4035646  PMID: 24960499
Situs inversus totalis; Laparoscopy-assisted distal gastrectomy; Gastric cancer
8.  Comprehension of readmission after laparoscopy assisted distal gastrectomy: what are the causes? 
Purpose
The aim of this study is to evaluate long-term outcomes regarding readmission for laparoscopy-assisted distal subtotal gastrectomy (LADG) compared to conventional open distal subtotal gastrectomy (CODG) for early gastric cancer (EGC).
Methods
Between January 2003 and December 2006, 223 and 106 patients underwent LADG and CODG, respectively, for EGC by one surgeon. The clinicopathologic characteristics, postoperative outcomes, postoperative complications, overall 5-year survival, recurrence, and readmission were retrospectively compared between the two groups.
Results
Multiple readmission rate in LADG was significantly less than that in CODG (0.4% vs. 3.8%, P = 0.039), although the readmission rate, reoperation rate after discharge, and mean readmission days were not significantly different between the two groups. Readmission rates of the LADG and CODG groups were 12.6% and 14.2%, respectively. First flatus time and postoperative hospital stay was significantly shorter in the LADG group. However, there was no significant difference in the complication rates between the two groups. Overall 5-year survival rates of the LADG and CODG group were 100% and 99.1% (P = 0.038), respectively.
Conclusion
Compared to the CODG group, the LADG group has several advantages in surgical short-term outcome and some benefit in terms of readmission in surgical long-term outcome for patients with EGC, even though the oncologic outcome of LADG is similar to that of CODG over 5 years.
doi:10.4174/astr.2014.86.5.237
PMCID: PMC4024929  PMID: 24851224
Laparoscopy; Gastrectomy; Gastric neoplasms; Patient readmission; Prognosis
9.  Port Site Metastasis After Laparoscopic-Assisted Distal Gastrectomy (LADG) 
International Surgery  2013;98(4):363-366.
This report describes a case of port site metastasis after laparoscopic gastrectomy for gastric cancer. A 57-year-old man with clinical cTNM stage II (T2 N0 M0) gastric cancer was admitted to our hospital. After administration of an oral fluoropyrimidine drug (S-1) for 2 weeks, he underwent laparoscopy-assisted distal gastrectomy (LADG). On hematoxylin and eosin staining, the pTNM stage was IA (T1b N0 M0). Eighteen months later, the patient developed a subcutaneous metastasis at the trocar site. A second operation was performed, and the abdominal wall mass was resected. The histological finding confirmed a diagnosis of metastatic gastric carcinoma. Immunohistochemical analysis revealed micrometastasis in fat tissue adjacent to the lymph node near the left gastric artery. Surgeons should be aware that port site metastasis can occur in patients undergoing LADG for gastric cancer with lymphatic micrometastasis, which is undetectable on routine hematoxylin and eosin staining.
doi:10.9738/INTSURG-D-13-00049.1
PMCID: PMC3829064  PMID: 24229024
Laparoscopic gastrectomy; Port site recurrence; Gastric cancer
10.  Comparison of liver function after laparoscopically assisted and open distal gastrectomies for patients with liver disease 
Surgical Endoscopy  2011;25(6):1761-1765.
Background
Several studies have suggested that carbon dioxide (CO2) pneumoperitoneum may have an effect on liver function. This study aimed to compare liver function after laparoscopically assisted distal gastrectomy (LADG) and open distal gastrectomy (ODG) for patients with liver disease.
Methods
Between January 2006 and December 2007, the study enrolled 50 patients with EGC and liver disease including 18 liver cirrhosis patients, 3 fatty liver patients (n = 3), and 29 healthy hepatitis B or C virus carriers. Albumin, total bilirubin, alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase levels as well as the volume of drainage in the LADG (n = 18) and ODG (n = 32) groups were determined to assess liver function.
Results
The albumin level on postoperative day 7 was significantly higher in the LADG group (3.5 mg/dl) than in the ODG group (3.1 mg/dl; p = 0.042), and the volume of drainage on postoperative day 2 was significantly lower in the LADG group (154.3 ml) than in the ODG group (403.1 ml; p = 0.013). Diuretics were needed by three patients (16.7%) in the LADG group and six patients (18.7%) in the ODG group for control of ascites (p = 0.587). For the patients with liver cirrhosis, none of the parameters between the two groups were significantly different.
Conclusion
For gastric cancer patients with chronic liver disease, LADG can be considered a safe surgical procedure showing surgical outcomes comparable with those for ODG.
doi:10.1007/s00464-010-1449-4
PMCID: PMC3098342  PMID: 21424207
Gastric cancer; LADG; Liver disease
11.  Comparison of the Invasiveness Between Reduced-Port Laparoscopy-Assisted Distal Gastrectomy and Conventional Laparoscopy-Assisted Distal Gastrectomy 
International Surgery  2013;98(3):247-253.
It is unknown whether reduced-port gastrectomy has a less invasive nature than conventional laparoscopy-assisted distal gastrectomy (C-LADG). So we compared 30 cases of dual-port laparoscopy-assisted distal gastrectomy (DP-LADG; using an umbilical port plus a right flank 5-mm port) as a reduced-port gastrectomy with 30 cases of C-LADG alternately performed by a single surgeon. No significant differences were observed in blood loss, intraoperative complications, the number of dissected lymph nodes, postoperative complications, the day of first defecation, analgesic agents required, changes in body temperature, heart rate, white blood cell count, serum albumin level, or lymphocyte count between the 2 groups. The amounts of oral intake in the DP-LADG group were significantly higher on postoperative days 9 and 10. We concluded that the amount of oral intake in the DP-LADG group was superior to that in the C-LADG group; however, no other evidence of DP-LADG being less invasive than C-LADG was obtained.
doi:10.9738/INTSURG-D-12-00025
PMCID: PMC3756848  PMID: 23971779
Laparoscopy; Gastrectomy; Single incision; Single port; Reduced port
12.  V-shaped lymph node dissection in laparoscopic distal gastrectomy; new technique of intra-abdominal dissection and surgical outcomes 
Background
Recently, laparoscopic-assisted distal gastrectomy (LADG) has become popular for the treatment of early gastric cancer. Furthermore, the use of totally laparoscopic gastrectomy (TLG), a more difficult procedure than LADG, has been increasing in Japan. Laparoscopic-assisted distal gastrectomy is currently performed more frequently than laparoscopic distal gastrectomy (LDG) in hospitals in Japan.
Method
Reconstruction after LDG is commonly performed extra-abdominally and lymph node dissection of the lesser curvature is performed at the same time. We have developed a new method of intra-abdominal lymph node dissection for the lesser curvature.
Results
Our technique showed positive results, is easy to perform, and is reasonable in terms of general oncology theory.
Conclusion
In oncological therapy, this technique could be a valuable surgical option for totally laparoscopic surgery.
doi:10.1186/1477-7819-10-205
PMCID: PMC3536664  PMID: 23021309
Laparoscopic gastrectomy; Lymph node dissection
13.  The current status and future perspectives of laparoscopic surgery for gastric cancer 
Gastric cancer is most common cancer in Korea. Surgery is still the main axis of treatment. Due to early detection of gastric cancer, the innovation of surgical instruments and technological advances, gastric cancer treatment is now shifting to a new era. One of the most astonishing changes is that minimally invasive surgery (MIS) is becoming more dominant treatment for early gastric cancer. These MIS are represented by endoscopic resection, laparoscopic surgery, robotic surgery, single-port surgery and natural orifice transluminal endoscopic surgery. Among them, laparoscopic gastrectomy is most actively performed in the field of surgery. Laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer (EGC) has already gained popularity in terms of the short-term outcomes including patient's quality of life. We only have to wait for the long-term oncologic results of Korean Laparoscopic Gastrointestinal Surgery Study Group. Upcoming top issues following oncologic safety of LADG are function-preserving surgery for EGC, application of laparoscopy to advanced gastric cancer and sentinel lymph node navigation surgery. In the aspect of technique, laparoscopic surgery at present could reproduce almost the whole open procedures. However, the other fields mentioned above need more evidences and experiences. All these new ideas and attempts provide technical advances, which will minimize surgical insults and maximize the surgical outcomes and the quality of life of patients.
doi:10.4174/jkss.2011.81.3.151
PMCID: PMC3204545  PMID: 22066116
Gastric cancer; Future perspective; Laparoscopy; Sentinel lymph node navigation surgery; Minimally invasive surgery
14.  Short-term surgical and long-term survival outcomes after laparoscopic distal gastrectomy with D2 lymphadenectomy for gastric cancer 
BMC Gastroenterology  2014;14:41.
Background
Laparoscopic distal gastrectomy (LDG) for gastric cancer has gradually gained popularity. However, the long-term oncological outcomes of LDG have rarely been reported. This study aimed to investigate the survival outcomes of LDG, and evaluate the early surgical outcomes of laparoscopy-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG).
Methods
Clinical outcomes of 240 consecutive patients with gastric cancer who underwent LDG at our institution between October 2004 and April 2013 were analyzed. Early surgical outcomes of LADG and TLDG were compared and operative experiences were evaluated.
Results
Of the 240 patients, 93 underwent LADG and 147 underwent TLDG. There were 109 T1, 36 T2, 31 T3, and 64 T4a lesions. The median follow-up period was 31.5 months (range: 4–106 months). Tumor recurrence was observed in 40 patients and peritoneal recurrence was observed most commonly. The 5-year disease-free survival (DFS) and overall survival (OS) rates according to tumor stage were 90.3% and 93.1% in stage I, 72.7% and 67.6% in stage II, and 34.8% and 41.5% in stage III, respectively. No significant differences in early surgical outcomes were noted such as operation time, blood loss and postoperative recovery between LADG and TLDG (P >0.05).
Conclusions
LDG for gastric cancer had acceptable long-term oncologic outcomes. The early surgical outcomes of the two commonly used LDG methods were similar.
doi:10.1186/1471-230X-14-41
PMCID: PMC3939636  PMID: 24568165
Stomach neoplasms; Gastrectomy; Laparoscopy; Lymphadenectomy; Survival
15.  Standardization of D2 lymphadenectomy and surgical quality control (KLASS-02-QC): a prospective, observational, multicenter study [NCT01283893] 
BMC Cancer  2014;14:209.
Background
Extended systemic lymphadenectomy (D2) is standard procedure for surgical treatment of advanced gastric cancer (AGC) although less extensive lymphadenectomy (D1) can be applied to early gastric cancer. Complete D2 lymphadenectomy is the mandatory procedure for studies that evaluate surgical treatment results of AGC. However, the actual extent of D2 lymphadenectomy varies among surgeons because of a lacking consensus on the anatomical definition of each lymph node station. This study is aimed to develop a consensus for D2 lymphadenectomy and also to qualify surgeons that can perform both laparoscopic and open D2 gastrectomy.
Methods/Design
This (KLASS-02-QC) is a prospective, observational, multicenter study to qualify the surgeons that will participate in the KLASS-02-RCT, which is a prospective, randomized, clinical trial comparing laparoscopic and open gastrectomy for AGC. Surgeons and reviewers participating in the study will be required to complete a questionnaire detailing their professional experience and specific gastrectomy surgical background/training, and the gastrectomy metrics of their primary hospitals. All surgeons must submit three laparoscopic and three open D2 gastrectomy videos, respectively. Each video will be allocated to five peer reviewers; thus each surgeon’s operations will be assessed by a total of 30 reviews. Based on blinded assessment of unedited videos by experts’ review, a separate review evaluation committee will decide whether or not the evaluated surgeon will participate in the KLASS-02-RCT. The primary outcome measure is each surgeon’s proficiency, as assessed by the reviewers based on evaluation criteria for completeness of D2 lymphadenectomy.
Discussion
We believe that our study for standardization of D2 lymphadenectomy and surgical quality control (KLASS-02-QC) will guarantee successful implementation of the subsequent KLASS-02-RCT study. After making consensus on D2 lymphadenectomy, we developed evaluation criteria for completeness of D2 lymphadenectomy. We also developed a unique surgical standardization and quality control system that consists of recording unedited surgical videos, and expert review according to evaluation criteria for completeness of D2 lymphadenectomy. We hope our systematic approach will set a milestone in surgical standardization that is essential for surgical clinical trials. Additionally, our methods will serve as a novel system for educating surgeons and assessing surgical proficiency.
Trial registration
NCT01283893.
doi:10.1186/1471-2407-14-209
PMCID: PMC4000001  PMID: 24646327
Neoplasms of stomach; D2 lymphadenectomy; Gastrectomy; Laparoscopy; Standardization; Quality control
16.  Comparison of Laparoscopy-Assisted and Totally Laparoscopic Distal Gastrectomy: The Short-Term Outcome at a Low Volume Center 
Journal of Gastric Cancer  2013;13(1):44-50.
Purpose
Laparoscopic gastrectomy has been adopted for the treatment of gastric cancer, and despite the technical difficulties, totally laparoscopic distal gastrectomy has been considered less invasive than laparoscopy-assisted distal gastrectomy. Although there have been many reports regarding the feasibility and safety of totally laparoscopic distal gastrectomy at large volume centers, few reports have been conducted at low-volume centers. The purpose of this study is to try to assess the feasibility and safety of totally laparoscopic distal gastrectomy at a low volume center through the analysis of short-term outcomes of totally laparoscopic distal gastrectomy compared with laparoscopy-assisted distal gastrectomy.
Materials and Methods
The clinical data and short-term surgical outcomes of 35 patients who had undergone laparoscopy-assisted distal gastrectomy between April 2007 and March 2010, and 37 patients who underwent totally laparoscopic distal gastrectomy between April 2010 and August 2012 were retrospectively reviewed.
Results
There was no significant difference in the demographic and clinical data. However the reconstruction method and extent of lymphadenectomy showed statistically significant differences. Operation time and estimated blood loss did not show significant differences. Surgical and medical complications did not show significant differences but postoperative courses including time-to-first oral intake and postoperative hospital stay were significantly increased.
Conclusions
Our study shows that totally laparoscopic distal gastrectomy is technically feasible at a low volume center. Therefore, totally laparoscopic distal gastrectomy can be considered as one of the surgical treatment for early gastric cancer. However the possibility that totally laparoscopic distal gastrectomy may have less benefit should also be considered.
doi:10.5230/jgc.2013.13.1.44
PMCID: PMC3627806  PMID: 23610718
Stomach neoplasms; Laparoscopy; Gastrectomy
17.  Comparison of laparoscopy-assisted and totally laparoscopic Billroth-II distal gastrectomy for gastric cancer 
Purpose
In laparoscopic distal gastrectomy for gastric cancer, most surgeons prefer extra-corporeal anastomosis because of technical challenges and unfamiliarity with intra-corporeal anastomosis. Herein, we report the feasibility and safety of intra-corporeal Billroth-II anastomosis in gastric cancer.
Methods
From April 2004 to March 2011, 130 underwent totally laparoscopic distal gastrectomy with intra-corporeal Billroth-II reconstruction, and 269 patients underwent laparoscopy-assisted distal gastrectomy with extra-corporeal Billroth-II reconstruction. Surgical efficacies and outcomes between two groups were compared.
Results
There were no differences in demographics and clinicopathological characteristics. The mean operation and reconstruction times of totally laparoscopic distal gastrectomy were statistically shorter than laparoscopy-assisted distal gastrectomy (P = 0.019; P < 0.001). Anastomosis-related complications were observed in 11 (8.5%) totally laparoscopic distal gastrectomy and 21 (7.8%) laparoscopy-assisted distal gastrectomy patients, and the incidence of these events was not significantly different. Post-operative hospital stays for totally laparoscopic distal gastrectomy were shorter than laparoscopy-assisted distal gastrectomy patients (8.3 ± 3.2 days vs. 9.9 ± 5.3 days, respectively; P = 0.016), and the number of times parenteral analgesic administration was required in laparoscopy-assisted distal gastrectomy patients was more frequent after surgery.
Conclusion
Intra-corporeal Billroth-II anastomosis is a feasible procedure and can be safely performed with the proper experience for laparoscopic distal gastrectomy. This method may be less time consuming and may produce a more cosmetic result.
doi:10.4174/jkss.2012.82.3.135
PMCID: PMC3294106  PMID: 22403746
Laparoscopic distal gastrectomy; Extra-corporeal anastomosis; Intra-corporeal anastomosis; Billroth-II anastomosis
18.  Reexpansion Pulmonary Edema following Laparoscopy-Assisted Distal Gastrectomy for a Patient with Early Gastric Cancer: A Case Report 
Case Reports in Surgery  2012;2012:863163.
We report here a case of reexpansion pulmonary edema following laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer. A 57-year-old Japanese woman with no preoperative comorbidity was diagnosed with early gastric cancer. The patient underwent LADG using the pneumoperitoneum method. During surgery, the patient was unintentionally subjected to single-lung ventilation for approximately 247 minutes due to intratracheal tube dislocation. One hour after surgery, she developed severe dyspnea and produced a large amount of pink frothy sputum. Chest radiography results showed diffuse ground-glass attenuation and alveolar consolidation in both lungs without cardiomegaly. A diagnosis of pulmonary edema was made, and the patient was immediately intubated and received ventilatory support with high positive end-expiratory pressure. The patient gradually recovered and was weaned from the ventilatory support on the third postoperative day. This case shows that single-lung ventilation may be a risk factor for reexpansion pulmonary edema during laparoscopic surgery with pneumoperitoneum.
doi:10.1155/2012/863163
PMCID: PMC3514816  PMID: 23227412
19.  The Impact of Obesity on the Use of a Totally Laparoscopic Distal Gastrectomy in Patients with Gastric Cancer 
Journal of Gastric Cancer  2012;12(2):108-112.
Purpose
Since a patient's obesity can affect the mortality and morbidity of the surgery, less drastic surgeries may have a major benefit for obese individuals. This study evaluated the feasibility of performing a totally laparoscopic distal gastrectomy, with intracorporeal anastomosis, in obese patients suffering from gastric cancer.
Materials and Methods
This was a retrospective analysis of the 138 patients, who underwent a totally laparoscopic distal gastrectomy from April 2005 to March 2009, at the National Kyushu Cancer Center. The body mass index of 20 patients was ≥25, and in 118 patients, it was <25 kg/m2.
Results
The mean values of body mass index in the 2 groups were 27.3±2.2 and 21.4±2.3. Hypertension was significantly more frequent in the obese patients than in the non-obese patients. The intraoperative blood loss, duration of surgery, post-operative complication rate, post-operative hospital stay, and a number of retrieved lymph nodes were not significantly different between the two groups.
Conclusions
Intracorporeal anastomosis seemed to have a benefit for obese individuals. Totally laparoscopic gastrectomy is, therefore, considered to be a safe and an effective modality for obese patients.
doi:10.5230/jgc.2012.12.2.108
PMCID: PMC3392321  PMID: 22792523
Laparoscopy; Gastrectomy; Stomach neoplasms; Obesity; Body mass index
20.  Laparoscopy-Assisted Distal Gastrectomy for an Early Gastric Cancer Patient With Situs Inversus Totalis 
International Surgery  2013;98(3):266-270.
Situs inversus totalis (SIT) is a congenital condition in which there is complete right to left reversal of the thoracic and abdominal organs. This report describes laparoscopy-assisted distal gastrectomy (LADG) for an early gastric cancer patient with SIT. The preoperative diagnosis was c-stage IA (cT1a cN0 cH0 cP0 cM0). LADG with D1+ dissection and Billroth-I reconstruction was successfully performed by standing at the opposite position. The operating time was 234 minutes and blood loss was 5 mL. Although a mechanical obstruction occurred after surgery, the patient recovered after re-operation with Roux-en-Y bypass.
doi:10.9738/INTSURG-D-13-00054.1
PMCID: PMC3756851  PMID: 23971782
Situs inversus; Laparoscopy; Stomach neoplasm; Minimal blood loss
21.  Laparoscopy-assisted versus open D2 radical gastrectomy for advanced gastric cancer without serosal invasion: a case control study 
Background
The application of laparoscopic surgery for advanced gastric cancer (AGC) remains questionable on account of technical difficulty of D2 lymphadenectomy, and there has been few large-scale follow-up results regarding the oncological adequacy of laparoscopic surgery compared with that of open surgeries for AGC. The aim of this study is to evaluate technical feasibility and oncological efficacy of laparoscopy-assisted gastrectomy (LAG) for advanced gastric cancer without serosal invasion.
Methods
From January 2008 to December 2012, 1114 patients with gastric cancer underwent D2 gastrectomy, including 336 T2 and T3 patients in term of depth of invasion. Of all 336 patients, 224 underwent LAG, while open gastrectomy (OG) performed on the other 112 patients. The comparison was based on the clinicopathologic characteristics, surgical outcome, and follow-up results.
Results
There are not significant differences in clinicopathological characteristics between the two groups (P > 0.05). The operation time and first ambulation time was similar in the two groups. However, estimated blood loss, bowel function recovery time and duration of hospital stay were significantly less in the LAG group. No significant difference in morbidity and mortality was found between the LAG group and OG group (11.1% vs. 15.3%, P = 0.266; 0.9% vs. 1.8%, P = 0.859). The mean number of resected lymph nodes (LNS) between the LAG group and OG group was similar (30.6 ± 10.1 vs. 30.3 ± 8.6, P = 0.786). Furthermore, the mean number of removed LNS in each station was not significantly different in the distal gastrectomy and total gastrectomy (P > 0.05). No statistical difference was seen in 1 year survival rate (91.5% vs. 89.8% P > 0.05) and the survival curve after surgery between the LAG group and OG group.
Conclusion
Laparoscopy-assisted D2 radical gastrectomy is feasible, effective and has comparative oncological efficacy compared with open gastrectomy for advanced gastric cancer without serosal invasion.
doi:10.1186/1477-7819-10-248
PMCID: PMC3514136  PMID: 23158876
Stomach neoplasms; Gastrectomy; Laparoscopy; Lymph node; D2 dissection
22.  Complete laparoscopic resection of the rectum using natural orifice specimen extraction 
World Journal of Gastroenterology : WJG  2014;20(44):16707-16713.
AIM: To investigate how complete laparoscopic anterior resection with natural orifice specimen extraction (NOSE), as a novel minimally invasive surgery, compares to conventional laparoscopic surgery.
METHODS: Twenty patients who underwent complete laparoscopic anterior resection with NOSE and 50 patients who underwent laparoscopic assisted anterior resection by the conventional method between 2011 and 2012 were studied. Selection for complete laparoscopic anterior resection with NOSE was decided on the basis of tumor size, localization of the tumor, and body mass index. Outcomes related to surgery, including operation time, postoperative wound pain, hospital stay after surgery, the number of totally dissected lymph nodes, postoperative complications (suture failure and wound infection), and anal function, were reviewed retrospectively. Anal function was assessed at 3 and 6 mo after surgery using the Wexner fecal incontinence scoring system.
RESULTS: Complete laparoscopic resection with NOSE was performed to completion in all 20 patients. There was no patient emergency that required conversion to conventional laparoscopic surgery or open surgery. The comparison between complete laparoscopic resection with NOSE and conventional laparoscopic surgery showed no significant differences in the maximal diameter of the tumor, number of totally dissected lymph nodes, bleeding volume, mean operation time, time to start of oral ingestion, postoperative hospital stay, and postoperative complications. On the other hand, with regard to pain after epidural anesthesia, the total usage of analgesia in this novel surgical technique was 1.85 ± 1.8 times, whereas it was 5.89 ± 2.86 in conventional laparoscopic surgery (P < 0.001). The postoperative pain period was 1.9 ± 1.9 d in this novel surgical technique, whereas it was 3.43 ± 1.41 d in conventional laparoscopic surgery (P < 0.004). In complete laparoscopic surgery with NOSE, the mean postoperative follow-up period was 20 mo (range: 12-30 mo). Neither local recurrence nor remote metastasis was observed during the follow-up period.
CONCLUSION: Complete laparoscopic anterior resection using NOSE does not require any incision and has excellent cosmetic properties, with mitigated postoperative pain.
doi:10.3748/wjg.v20.i44.16707
PMCID: PMC4248216  PMID: 25469041
Complete laparoscopic surgery; Incisionless surgery; Natural orifice specimen extraction; Transanal specimen extraction; Less invasive surgery
23.  Laparoscopic splenic hilum lymph node dissection for advanced proximal gastric cancer: A modified approach for pancreas- and spleen-preserving total gastrectomy 
AIM: To investigate the feasibility and optimal approach for laparoscopic pancreas- and spleen-preserving splenic hilum lymph node dissection in advanced proximal gastric cancer.
METHODS: Between August 2009 and August 2012, 12 patients with advanced proximal gastric cancer treated in Nanfang Hospital, Southern Medical University, Guangzhou, China were enrolled and subsequently underwent laparoscopic total gastrectomy with pancreas- and spleen-preserving splenic hilum lymph node (LN) dissection. The clinicopathological characteristics, surgical outcomes, postoperative course and follow-up data of these patients were retrospectively collected and analyzed in the study.
RESULTS: Based on our anatomical understanding of peripancreatic structures, we combined the characteristics of laparoscopic surgery and developed a modified approach (combined supra- and infra-pancreatic approaches) for laparoscopic pancreas- and spleen-preserving splenic hilum LN dissection. Surgery was completed in all 12 patients laparoscopically without conversion. Only one patient experienced intraoperative bleeding when dissecting LNs along the splenic artery and was handled with laparoscopic hemostasis. The mean operating time was 268.4 min and mean number of retrieved splenic hilum LNs was 4.8. One patient had splenic hilum LN metastasis (8.3%). Neither postoperative morbidity nor mortality was observed. Peritoneal metastasis occurred in one patient and none of the other patients died or experienced recurrent disease during the follow-up period.
CONCLUSION: Laparoscopic total gastrectomy with pancreas- and spleen-preserving splenic hilum LN dissection using the modified approach for advanced proximal gastric cancer could be safely achieved.
doi:10.3748/wjg.v19.i30.4992
PMCID: PMC3740431  PMID: 23946606
Proximal stomach; Stomach neoplasm; Laparoscopy; Lymph node excision; Splenic hilum
24.  Port site herniation of the small bowel following laparoscopy-assisted distal gastrectomy: a case report 
Introduction
Port-site herniation is a rare but potentially dangerous complication after laparoscopic surgery. Closure of port sites, especially those measuring 10 mm or more, has been recommended to avoid such an event.
Case presentation
We herein report the only case of a port site hernia among a series 52 consecutive cases of laparoscopy-assisted distal gastrectomy (LADG) carried out by our unit between July 2002 and March 2007. In this case the small bowel herniated and incarcerated through the port site on day 4 after LADG despite closure of the fascia. Initial manifestations experienced by the patient, possibly due to obstruction, and including mild abdominal pain and nausea, occurred on the third day postoperatively. The definitive diagnosis was made on day 4 based on symptoms related to leakage from the duodenal stump, which was considered to have developed after severe obstruction of the bowel. Re-operation for reduction of the incarcerated bowel and tube duodenostomy with peritoneal drainage were required to manage this complication.
Conclusion
We present this case report and review of literature to discuss further regarding methods of fascial closure after laparoscopic surgery.
doi:10.1186/1752-1947-2-48
PMCID: PMC2276505  PMID: 18275616
25.  Three-step hand-assisted laparoscopic surgery for radical distal gastrectomy: an effective surgical approach 
Objective: Three-step hand-assisted laparoscopic D2 radical gastrectomy (HALG) is a modified surgical technique based on hand-assisted laparoscopic surgery (HALS) for the treatment of gastric cancer. This surgical approach is particularly easy and convenient for radical distal gastrectomy. In order to thoroughly understand the advantages of applying “three-step HALG” in distal gastrectomy, our center conducted a retrospective study to analyze data from patients who underwent HALG and laparoscopic-assisted D2 radical gastrectomy (LAG) during the corresponding time period. Methods: The HALG procedure is performed in three steps, namely the operation performed through an auxiliary incision under direct vision, hand-assisted laparoscopic operation, and gastrointestinal tract reconstruction through the auxiliary incision under direct vision. This study performed comprehensive, in-depth comparative analyses on the clinical data of two groups of patients who underwent HALG and LAG. Results: The auxiliary incision under the xiphoid was maximally utilized in the HALG procedure. The rate of conversion to open surgery in HALG group patients was significantly lower than in the LAG group (P = 0.03), and the operating time was significantly shorter in the HALG group than in the LAG group (P = 0.00). There was no significant difference in the pain rate score on postoperative day 2 and on the day of discharge between the HALG and LAG groups (P > 0.05). No statistically significant difference was found in the time to recovery of bowel function, postoperative hospital stay, or postoperative complications (P > 0.05), although the values were all lower in the HALG group than in the LAG group. Conclusion: “Three-step HALG” is a highly feasible surgical approach for radical distal gastrectomy.
PMCID: PMC4161561  PMID: 25232401
Hand-assisted laparoscopic surgery; three-step hand-assisted laparoscopic D2 radical gastrectomy; laparoscopic-assisted D2 radical gastrectomy; distal gastrectomy

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