Minimally invasive surgery for remnant gastric cancer: a comparison with open surgery

Abstract

Background Completion total gastrectomy for remnant gastric cancer (RGC) is technically challenging, especially using the minimally invasive approach. Only a few small case series have reported the technical feasibility of completion total gastrectomy by minimally invasive surgery (MIS). The aim of this study was to compare the efficacy and safety of MIS and open surgery for RGC. Methods We retrospectively analyzed 76 completion total gastrectomies for RGC between 2005 and 2012. Indications for MIS were limited to no evidence of serosa invasion or lymph node metastasis to extraperigastric areas on preoperative evaluation. We compared patient characteristics, intraoperative factors, post-operative outcomes, and survival for the MIS and open surgery groups. Results Eighteen patients underwent completion total gastrectomy with MIS (10 laparoscopic, 8 robotic) and 58 patients underwent open surgery. Operation time was longer in the MIS than the open group (266 vs. 203 min, P = 0.004), but the groups had similar estimated blood loss, frequency of unplanned other organ resection, and number of retrieved lymph nodes. The MIS group had a significantly earlier initiation of soft diet, shorter hospital stay, and fewer pain medication injections. Complication rates, recurrence, and overall 5-year survival were similar for the two groups. When we compared laparoscopy with robotic, similar result was shown in all parameters except operation time. Conclusions Compared to open surgery, MIS for RGC demonstrated better short-term outcome and comparable oncologic results. MIS for RGC is feasible and safe and maintains advantages of minimal invasiveness. Both laparoscopic and robotic approaches are reasonable to the management of RGC. Keywords Minimally invasive surgery Remnant gastric cancer Stomach Completion total gastrectomy Remnant gastric cancer was originally defined as gastric cancer arising after distal gastrectomy for benign disease [1, 2]. More recently, remnant gastric cancer has been used to refer to all cancers arising in the remnant stomach, regardless of the initial disease or operation [3–5]. As patients with gastric cancer are now surviving longer because of early diagnosis and improved prognosis, remnant gastric cancer after gastrectomy for malignant disease is becoming more common, especially in Eastern countries [6–8]. At the same time, remnant gastric cancer is often diagnosed at a relatively early stage because of regular patient follow-up after gastrectomy for cancer [9]. Thus, an increasing number of remnant gastric cancers are detected at a resectable stage, which can be treated by surgical resection as a primary gastric cancer. Standard surgery for remnant gastric cancer involves removing the entire remnant stomach with lymph node dissection; this is known as a completion total gastrectomy with lymph node dissection. This procedure is most often performed as open surgery since minimally invasive surgery (MIS) is not usually indicated for patients who have undergone previous major abdominal surgery because of technical difficulties due to adhesions and anatomical alterations from the previous surgery. With advances in laparoscopic techniques and devices, the accumulating experience of surgeons, and the wider acceptance of MIS for gastric cancer in general, MIS for remnant gastric cancer is gaining interest. However, the literature in this area is sparse, and only a few small case series have described completion total gastrectomy successfully performed by the laparoscopic approach [10–12]. There is only one study with a small number of cases that compared outcomes after laparoscopic approach for remnant gastric cancer with open surgery [13]. To the best of our knowledge, no study has compared MIS with open surgery for the treatment of remnant gastric cancer, including robotic surgery. The aim of this study was to assess the effectiveness and safety of MIS for remnant gastric cancer. We compared the short-term and long-term outcomes of minimally invasive completion total gastrectomy with those of open completion total gastrectomy to determine whether benefits of MIS are observed in patients undergoing this technically complex operation.