Laparoscopic completion gastrectomy in elderly patients with remnant gastric cancer: a case series

Abstract

Background Open completion gastrectomy (OCG) has been selected to treat remnant gastric cancer (RGC) due to severe adhesions and difficulty recognizing anatomical orientation after primary gastrectomy. In general, elderly individuals’ physiological reserves gradually decrease. Moreover, elderly patients (EPs) often have multiple complicating factors (i.e., frailty and comorbidities), leading to more postoperative complications after abdominal surgery. Recently, several trials revealed the advantages of laparoscopic surgery for EPs with gastric cancer in early recovery. However, there are limited studies investigating the use of laparoscopic completion gastrectomy (LCG) for RGC in EPs. This study aims to assess the efficacy of LCG in EPs aged ≥ 70 years. We compared the short- and long-term outcomes of LCG with those of OCG. Case presentation Twenty-one EPs who underwent completion gastrectomy for RGC between 2007 and 2017 were enrolled and classified into two groups according to the surgical approach, namely the LCG ( n = 6) and OCG ( n = 15) groups. We adopted the G8 geriatric screening tool to comprehensively evaluate the EPs’ physical, mental, and social functions. Patient characteristics, clinicopathological characteristics, surgical outcomes, and survival were retrospectively reviewed and compared between groups. Results There was no significant difference in the preoperative modified G8, indicating that the EPs’ backgrounds between the groups were comparable. Of note, blood loss during surgery was significantly reduced in the LCG group [median (range); LCG, 50 ml (20.0–65.0); OCG, 465 ml (264.5–714.0); p = 0.002]. The median number of retrieved lymph nodes in the LCG and OCG groups were 7 (range 4–10) versus 3 (range 1–6), respectively. There were no statistically significant differences in postoperative hospitalization, intake of solid food, and Clavien–Dindo grade ≥ II postoperative complications. In patients with a history of gastrectomy for gastric cancer in the LCG group, operative time tended to be longer in patients who underwent D2 lymph node dissection as primary surgery. Conclusions LCG was comparable to OCG for the treatment of RGC in EPs with significantly reduced blood loss. While LCG should be selected with caution in patients who have undergone D2 lymph node dissection as primary surgery, it could be considered as a surgical procedure in EPs with RGC.

Laparoscopic Total Gastrectomy for Remnant Gastric Cancer: A Single-institution Experience and Systematic Literature Review

“…Six studies reported that the conversion rate to open gastrectomy was 5.6-47.1%; the other 15 studies reported no cases of conversion to open gastrectomy. In all studies, the mean operation time ranged from 197 to 487 min, the mean blood loss was up to 425 g, the mean number of retrieved lymph nodes ranged from 7 to 26 and the mean duration of postoperative hospital stay (18)(19)(20)(21)(22)(23)(24). Among these 8 studies, 6 studies showed that LTG was associated with less blood loss, 4 studies showed that LTG was associated with a longer operation time, and 1 study showed that LTG was associated with a greater number of retrieved lymph nodes and shorter postoperative hospital stay in comparison to the OTG group.…”

“…This means that laparoscopic surgery takes longer to perform, but also that even under severe adhesion, laparoscopic surgery with a magnified view and technical advances may contribute to the performance of a safe and secure operation for RGC. Only 4 reports including our own have described long term clinical outcomes, and all of these studies indicated comparable survival rates between LTG and OTG groups (18,19,24). However, conclusions have not been reached because of the short follow-up time periods (median 21-39.1 months).…”

Current controversies in treating remnant gastric cancer: Are minimally invasive approaches feasible?

“…Therefore, we reviewed all published English language literature on LG for RGC to better characterize the technical aspects of the currently used procedures (Table 3). Recently, ten non-RCT studies with a small series of patients compared the perioperative results of LG for RGC with those of open gastrectomy (OG)[60-69].…”

“…All studies comparing the operating time between OG and LG reported that LG required more time than OG, even though the difference was not statistically significant in five out of the ten studies[64-66,68,69]. However, LG was associated with lower intraoperative blood loss than OG in six of the ten studies[60,61,65,66,68,69]. The number of resected lymph nodes was reported in all non-RCTs and case studies.…”

“…In terms of the postoperative complication rate, five of the ten studies reported a 6.5%–23.3% risk reduction with LG compared to that of OG[60,62,64,65,68]. The remaining five studies showed unfavorable results from the laparoscopic approach in terms of the postoperative mortality rate, although the result was not statistically significant[61,63,66,67,69]. LG was also associated with a significantly shorter postoperative hospital stay than OG, as shown in one of the non-RCTs.…”