Laparoscopy-Assisted Distal Gastrectomy for Cancer

Chapter 11 Laparoscopy-Assisted Distal Gastrectomy for Cancer



Seigo Kitano, Yohei Kono, Norio Shiraishi


The videos associated with this chapter are listed in the Video Contents and can be found on the accompanying DVDs and on Expertconsult.com.image


Gastric cancer is one of the most common cancers worldwide with about 989,600 new cases and 738,000 deaths per year, accounting for about 8% of new cancers. Early gastric cancer (EGC) is defined by the Japanese Gastric Cancer Association guidelines as the cancer contained to the gastric mucosa or submucosa despite lymph node (LN) metastasis. Recently, the incidence of EGC has increased in Asian countries, presumably because of advances in diagnostic modalities (endoscopy technology and examination technique) and the popularity of mass screening (e.g., yearly barium meal study). The incidence of stage I gastric cancer is 1.5 times higher than that of other gastric cancer in Japan. The main strategy against gastric cancer, including EGC, is surgical removal of the cancer cells. For the treatment of gastric cancer with the risk for LN metastasis, gastrectomy with LN dissection is routinely performed in Asian countries.


Laparoscopy-assisted distal gastrectomy (LADG) with dissection of regional LNs for the treatment of EGC was developed in 1991. Since then, the number of LADGs has rapidly increased because of the high incidence of gastric cancer located in the distal stomach, especially in Asian countries. This chapter will focus on LADG. The rapid popularization of LADG has been based on advances in surgical technique and the development of several laparoscopic surgical instruments, such as laparoscopic coagulation shears and a laparoscopic vessel-sealing system. In Japan, more than 34,600 patients with EGC underwent laparoscopic gastrectomy between 1991 and 2009, and in 2009 alone, more than 5500 patients with gastric cancer underwent LADG.


Laparoscopic techniques have several disadvantages compared with traditional open surgical techniques, including loss of touch sensation and the necessity of using long forceps in a two-dimensional work environment. Previously it had seemed difficult to apply laparoscopic techniques to gastrectomy for cancer across a large number of hospitals. Several study groups in Japan and Korea, however, have conducted numerous conferences and organized training courses to standardize the techniques of LADG with less invasiveness. As a result, LADG with LN dissection is now performed safely in patients with gastric cancer, especially those with EGC, in many centers across Asia. Herein we discuss the present status of LADG in Japan, including the indications for and techniques of LADG.



Operative indications


The indication for LADG is EGC with risk for LN metastasis and advanced gastric cancer (AGC) without serosal invasion, all located in the distal two thirds of stomach. The incidence of LN metastasis in EGC is about 5% to 20%. With the development of endoscopic submucosal dissection (ESD) techniques, EGC without risk for LN metastasis is treated by ESD. The Japanese Gastric Cancer Association guidelines define EGC with a risk for LN metastasis as follows: (1) well-differentiated mucosal cancer of more than 2.0 cm in diameter, (2) well-differentiated mucosal cancer with ulceration, (3) poorly differentiated mucosal cancer, and (4) submucosal cancer. LADG is applied to these conditions, which are diagnosed by endoscopic examination, barium meal examination, and computed tomography (CT) findings as ECG with risk for LN metastasis.


The indication of LADG for advanced cancer remains controversial because of the lack of clinical evidence of oncologic safety. Most surgeons who perform open surgery worry about the possibility of an increased incidence of port-site recurrence and peritoneal metastasis. Therefore, LADG in Japan is applied to AGC without serosal invasion and lymph node status of N2 or higher. The extent of LN dissection in Japan is determined according to the predicted frequency of LN metastasis. The Japanese Gastric Cancer Association guidelines indicate the following: D1 or D1+ for EGC, and D2 for AGC (see definitions in Fig. 11-1 and Tables 11-1 and 11-2).


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FIGURE 11-1 Regional lymph nodes.


(Adapted from Japanese Gastric Cancer Association: Japanese classification of gastric carcinoma, 2nd English edition. Gastric Cancer 1:10–24, 1998.)


Table 11-1 Lymph Node Stations of the Japanese Classification System for Gastric Cancer*









































































































No. Description
1 Right paracardial LN
2 Left paracardial LN
3 LN along the lesser curvature
4sa LN along the short gastric vessels
4sb LN along the left gastroepiploic vessels
4d LN along the right gastroepiploic vessels
5 Suprapyloric LN
6 Infrapyloric LN
7 LN along the left gastric artery
8a LN along the common hepatic artery (anterosuperior group)
8p LN along the common hepatic artery (posterior group)
9 LN around the celiac artery
10 LN at the splenic hilum
11p LN along the proximal splenic artery
11d LN along the distal splenic artery
12a LN in the hepatoduodenal ligament (along the hepatic artery)
12b LN in the hepatoduodenal ligament (along the bile duct)
12p LN in the hepatoduodenal ligament (behind the portal vein)
13 LN on the posterior surface of the pancreatic head
14v LN along the superior mesenteric vein
14a LN along the superior mesenteric artery
15 LN along the middle colic vessels
16a1 LN in the aortic hiatus
16a2 LN around the abdominal aorta (from the upper margin of the celiac trunk to the lower margin of the left renal vein)
16b1 LN around the abdominal aorta (from the lower margin of the left renal vein to the upper margin of the inferior mesenteric artery)
16b2 LN around the abdominal aorta (from the upper margin of the inferior mesenteric artery to the aortic bifurcation)
17 LN on the anterior surface of the pancreatic head
18 LN along the inferior margin of the pancreas
19 Infradiaphragmatic LN
20 LN in the esophageal hiatus of the diaphragm
110 Paraesophageal LN in the lower thorax
111 Supradiaphragmatic LN
112 Posterior mediastinal LN

* See Fig. 11-1 for illustration of station positions.


Data from Japanese Gastric Cancer Association: Japanese classification of gastric carcinoma, 2nd English edition. Gastric Cancer 1:10–24, 1998.


Table 11-2 Extent of Lymph Node Dissection (D Type) with Respect to Gastric Tumor Stage for Distal Gastrectomy*



















Type Stations Applicable Tumor Stage
D1 1, 3, 4sb, 4d, 5, 6, 7 T1a tumor without indication for endoscopic resection; well-differentiated T1b tumor smaller than 1.5 cm with cN0
D1+ D1 stations, plus 8a, 9 T1 tumor with cN0 (other than listed above)
D2 D1 stations, plus 8a, 9, 11p, 12a T1 tumor with cN(+); resectable T2 (or deeper) tumor

* See Fig. 11-1 and Table 11-1 for definition of lymph node stations; see Table 11-3 for tumor staging.



Preoperative evaluation, testing, and preparation


Preoperative evaluation should stage the gastric cancer and the patient’s systemic tolerance to surgical stress. Gastric tumor staging as defined by the American Joint Committee on Cancer (AJCC) is shown in Table 11-3. For the staging of gastric cancer, endoscopic examination (with biopsy and ultrasound) and barium meal study are used to evaluate the location, histologic type, size, and depth of wall invasion of the gastric cancer. Ultrasound examination and CT are used to evaluate invasion to other organs, nodal metastasis, hematogenous metastasis, and peritoneal dissemination. AGC without serosal exposure (T2) is diagnosed by laparoscopic examination under the same anesthetic as LADG. An algorithm of treatment selection for various subtypes of EGC and AGC is shown in Figure 11-2. To determine systemic tolerance to surgical stress, heart, respiratory, liver, and kidney function are evaluated in the same manner as with open surgery.



Table 11-3 TNM Staging for Gastric Cancer

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FIGURE 11-2 Treatment algorithm for gastric cancer in Japan.


As of 2011, there is no convincing evidence that neoadjuvant chemotherapy for gastric cancer produces a clinically relevant improvement in survival. A phase III study of neoadjuvant chemotherapy involving bulky T3-4 gastric cancer is ongoing in Japan. Currently, adjuvant chemotherapy with S-1 (a formulation containing tegafur, gimeracil, and oteracil) is recommended for patients in Japan with stage II or III advanced gastric cancer after resection. There is no special preoperative preparation for LADG. Because the morbidity rate associated with LADG may be increased with obese patients (BMI >30 kg/m2), the relative merits of LADG in the obese patient should be carefully considered. Prophylactic antibiotics are administered only on the operative day (30 minutes before skin incision, every 3 hours through the operation, and then one more dose several hours after the procedure).

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Jul 20, 2016 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Laparoscopy-Assisted Distal Gastrectomy for Cancer

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