Laparoscopic gastrectomies for cancer

Early outcomes of laparoscopic gastric resection for

adenocarcinoma

Eduardo A. Guzman MD

Alessio Pigazzi MD PhD

Joshua D.I. Ellenhorn MD

Laparoscopy for cancer

• A laparoscopic approach should not compromise the quality of the surgery

• Laparoscopic procedures have been succesfully adopted for colon cancer given equivalent oncologic outcomes

• Laparoscopic gastrectomy for cancer is commonly performed in Asia and Europe

• Laparoscopic gastrectomy experience in North America is limited

Extended lymphadenectomies

• Despite the results of randomized controlled trials, extended lymphadenectomies are still considered oncologically advantageous procedures.

• Judgement should be used to avoid consequential increases in morbidity and mortality

• Routine performance of a distal pancreatectomy and splenectomy should be avoided

Study aim

• Aim: To compare short term postoperative and oncologic outcomes between laparoscopic and open procedures for gastric adenocarcinoma

• Hypothesis: There is no difference in the rate of positive surgical margins or number of enlarged lymph nodes between laparoscopic and open procedures for gastric cancer

Methods

• Retrospective review of City of Hope surgical

database 1999 - 2008

• 143 patients underwent a gastric resection

• 67 patients were identified in accordance with

the specified inclusion and exclusion criteria

Methods

• Inclusion criteria– Gastric Adenocarcinoma– Abdominal procedures

– Curative interventions

• Exclusion criteria– Other cancers (GIST, tumors invading the stomach)– Palliative procedures– Esophagogastrectomies

– Thoracoabdominal approaches

Laparoscopic candidates

• Patients with no evidence of enlarged lymph nodes on preoperative imaging (CT / EUS) were identified as appropriate candidates for the laparoscopic procedure

Lymphadenectomy

• D0 - No

lymphadenectomy

• D1 – Perigastric nodes

• D2 - Nodes along the

celiac, splenic and hepatic

arteries.

• D3 - Removal of para-

aortic and retroperitoneal

nodes

D2 lymphadenectomies

• A D2 lymphadenectomy was considered in all patients with gastric cancer

• Some patients underwent a D1 instead due to early stage tumors or comorbid conditions that precluded a more extensive operation

Surgical technique• Pneumoperitoneum and placement of trocars • Omentectomy• Mobilization of the greater curvature of the stomach• Division of the right gastroepiploic vessels• Dissection of hepatoduodenal ligament next to the liver• Division of right gastric artery • Docking of robot• Dissection of all lymphatic tissue from hepatic, splenic

arteries and celiac plexus• Division of left gastric artery at its base• Gastric transection with wide margins• Laparoscopic gastrojejunostomy or esophagojejunostomy• Jejunostomy tube• Removal of specimen

Robotics

• The Da’Vinci surgical robot was used to assist in the perfromance of a D2 lymphadenectomy in a subset of patients

• Robotics provided improved visualization, tremor control and precise surgical dissection

• A D2 lymphadenectomy can also be performed purely laparoscopically

149 gastric resections1999 - 2008

67 patients

22 Laparoscopic 45 open

Inclusion and exclusion criteria

Vs

D0 = 0

D1 =

D2 =

D0 = 1

D1 =

D2 =

Patient characteristics

Laparoscopic(n=21)

Open (n=44) p-value

Age (mean) Xxx xxx xxx

Gender (% male) 67 64 0.842

BMI (median) 25 25 Put p value

No difference among groups in patient demographics

TNM

Laparoscopic Open p-value

T status 0.2537

T1 43 % (27)

T2 (38) (55)

T3 (14) (18)

T4 (5) (0)

N status 0.004

N0 (81) (32)

N1 (19) (43

N2 (0) (11)

N3 (0) (14)

Given preoperative selection criteria, patients in the laparoscopic group were more likely more likely to be node negative

Laparoscopic (n=21) Open (n=44) p-value

Stage 0.1156

0 0 (0) 1 (2)

I 13 (62) 15 (34)

II 7 33) 15 (34)

III 1 (5) 6 (14)

IV 0 (8) 7 (16)

There is no significant difference in the stage of disease between groups

Operative factors

Laparoscopic(n=21)

No. of patients (%)

Open (n=44) No. of

patients (%)

p-value

Surgical type 0.1378

Total 1( 5) 11 (25)

Proximal 3 (14) 6 (14)

Distal 17 (81) 27 (61)

Multiorgan resection 1 (5) 4 (9) 0.9086

No difference in type of surgery

Laparoscopic(n=21)(%)

Open (n=44) (%)

p-value*

Lymphadenectomy type 0.4379

D00 2

D133 20

D267 77

No difference in the percentage of patients who underwent an extended lymphadenectomy

In one patient a lymphadenectomy was completely avoided secondary to a T1 tumor and the presence of significant comorbid conditions

In 90x % of the laparoscopic patients, the lymphadenectomy was performed robotically

Operative outcomes

Laparoscopic

(n=21)

Open(n=44) p-value*

Surgery time (minutes), median (range)

411 299 <0.0001

Estimated blood loss, median (range) 200 383 0.0050

Laparoscopic procedures took longer but were associated with a lower blood loss

Oncologic outcomes

Laparoscopic(n=21)(%)

Open (n=44) (%) p-value*

Positive margins 0 2 0.4863

Number of lymph nodes, mean

26 26 0.98

Number of lymph nodes, mean D2 lymphadenectomy cases

26 26 0.98

Oncologic outcomes

• A margin negative resection was able to be accomplished in all but one patient.

• No difference in the median number of lymph nodes retreived between lap and open

• For D2 lymphadenectomy procedures, there was no difference in the median number of nodes harvested.

Postoperative outcomes

Laparoscopic

(n=21)

Open(n=44)

p-value*

Length of stay (days), median (range)

7 (3-50) 10 (3-60)

0.0034

% Weight loss at 1 month, median (range)

5.7 8.0 0.49

Median length of stay was significantly shorter in laparoscopic gastrectomies

At one month after surgery the percentage of weight lost was not significantly different between but there was a trend favoring the laparoscopic group

Morbidity and Mortality

Laparoscopic

(n=21)

Open(n=44)

p-value*

Mortality, N (%) 0 (0) 1 (2) 0.4863

Complications, N (%) 8 (38) 20 (45) 0.4863

Arrhythmia 2 7

Delayed gastric emptying 1 4

Anastomotic leak 1 0

Duodenal stump leak 1 0

Other 5 23

No significant difference in morbidity and mortality among both groupsThere was one death in the open armOne leak occurred in the laparoscopic arm. Cardiac arrythmias were the most common postoperative complication

Postoperative outcomes

• Median length of stay was shorter in the laparoscopic group

• No difference in the median % wt loss at one month

• No difference in the number of patients who suffered a postoperative complication

• One mortality in the open group

Summary

• Laparoscopic gastrectomies were associated with

• Decreased blood loss• Decreased length of stay

– But• Increased operative time

• There is no difference in the oncologic outcomes of negative margin resection and number of lymph nodes retreived

• An appropiate D2 lymphadenectomy can be performed laparoscopically or robotically

Summary

• Extended lymphadenectomy remains an important consideration in the surgical tx of gastric CA

• Laparoscopic gastric resections for cancer are being introduced in North America

• In our study– Oncologic outcomes were not compromised by the performance

of a laparoscopic procedure – Robotic extended lymphadenectomies were used– Lap procedures were associated with

• Increased op time• Decreased blood loss• Decreased length of Stay

Conclusion

• Lap gastrectomy is an oncologically adequate alternative to open surgical resection

• Lap procedures can be associated with improved short term postoperative outcomes

Future

• Increased use of laparoscopic gastric resections

• Incorporation of robotics in surgical oncology

• Multicenter randomized trials on laparoscopic gastrectomies