Laparoscopic gastrectomy was applied in the surgical management of gastric cancer in recent decades[1], its application is being propagated progressively. Especially in Asian countries such as Japan and Korea, it has become a standard therapy for early stage gastric cancer[2,3]. But there are still controversies about the feasibility of laparoscopic radical gastrectomy for cancer of the stomach, and one of the most concerned questions is about the curability of laparoscopic gastrectomy. Since 1998, laparoscopic gastrectomy was performed in our institution for gastric cancer. So we would like to give an analysis about our 10-year experience about it, and make a comparison with open surgery in some aspects, so to evaluate its curability and feasibility for gastric cancer. 濟南軍區總醫院普通外科張小橋
Materials and methods
Patients and operative procedures
All the gastric cancer patients treated with laparoscopic surgery from Jan, 1998 to Dec, 2007 were enrolled. Patients who received only laparoscopic exploration and the cases with conversion to laparotomy were excluded.
All the patient received operation under general anesthesia on a supine position with legs apart. The operation was performed with five-ports technique. The pressure of CO2 pneumoperitoneum was 8-10mmHg. Mobilization of the stomach and dissection of perigastric lymph node were performed following the Japanese Gastric Cancer Association (JGCA) gastric cancer treatment guidelines[4]. The range of gastric resection and extent of lymphatic dissection were determined according to the location of the primary lesion and clinical stage. The type of gastric resection included mucosectomy, wedge resection, segmental gastrectomy, laparoscopic (assisted) pyloric preserving gastrectomy (LPPG), laparoscopic (assisted) distal gastrectomy (LDG), laparoscopic (assisted) proximal gastrectomy (LPG) and laparoscopic (assisted) total gastrectomy (LTG). The lymphatic dissection included D0, which means no lymphatic dissection or incomplete dissection of group1 lymph nodes; D1, dissection of group 1 lymph nodes; D1+α, dissection of group 1 lymph nodes plus No. 7 and No. 8a lymph nodes if the primary focus located in the lower third of the stomach; D1+β, dissection of group 1 lymph nodes plus No. 7, No. 8a and No. 9 lymph nodes; and D2, which refers to the dissection of all the group 1 and 2 lymph nodes. In some cases, the lymphadenectomy with extent between D1 and D2 was defined as selective D2(sD2). For each operation, a self-evaluation about the curative potential was performed by the operator as Resection A, B or C according to the Japanese Classification of Gastric Carcinoma of JGCA[5].
Variables
General and clinicopathological data of eligible patients were retrieved from the medical reports and reviewed retrospectively. The variables included gender, age, pathological stage according to the Japanese Classification of Gastric Carcinoma[5], operative procedures and the extent of lymphatic dissection, the number of dissected lymph nodes and those with metastasis, the status of specimen margin and the distances from the lesion to the proximal and distal margin (proximal distance and distal distance). In cases after endoscopic mucosal resection (EMR), the distance was measured from the margin of scar following EMR.
Evaluation of curability
According to the Japanese Classification of Gastric Carcinoma of JGCA and Gastric Cancer Clinical Practice Guidelines of the National Comprehensive Cancer Network(NCCN), the criteria for the extent of a possibly curable gastric cancer operation included: no involvement of the proximal and distal margins with no less than 10 mm proximal and distal distances, enough lymph node dissection with no less than 15 lymph node dissected[6]. All the eligible patients were evaluated with this criteria. The curability related variables were compared among different operative procedures and lymph node dissections.
Comparison of curability between laparoscopic and open radical gastrectomy with D2 dissection
To compare the curability of operation between laparoscopic and open radical gastrectomy, procedures with D2 dissection were evaluated. All cases of laparoscopic gastrectomy with D2 dissection were enrolled. Cases of open radical gastrectomy (Resection A or B) with D2 dissection in recent 2 years were selected as the control group, with an exclusion of patients with combined splenectomy. The number of dissected lymph nodes, the proximal and distal distances were compared.
Statistics
All the continuous variables were expressed as mean±SD. Student’s t test, one-way ANOVA (analysis of variance) and Dunnett’s C test were used for comparison and post hoc multiple comparison of means. χ2 test (Pearson Chi-Square test) was used for analysis of categorical variables.
P
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