Abstract
Surgery for RGC can generally be difficult because of the severity of intra-abdominal adhesion due to past gastrectomy. Laparoscopic gastrectomy for RGC has been reported in some cases, but the adequacy of this procedure is still unclear. Herein we report four cases of RGC that underwent laparoscopic gastrectomy at our Hospital and discuss the benefit of the laparoscopic approach for RGC.
Remnant gastric cancer (RGC) is defined as cancer arising in the residual stomach after gastrectomy for either benign or malignant disease (1). It has been reported that RGC occurs in 2-3% of patients who have undergone partial gastrectomy and in 1.8% of all gastric cancer cases (2-4). The treatment for RGC is important because the incidence of RGC is expected to increase concomitant with an ageing society, and due to the progression of the prognoses of primary gastric cancer. Surgery for RGC is generally more difficult than for primary gastric cancer because of severe adhesion to surrounding organs, especially to the liver and pancreas, and displacement of anatomical structures (5).
Recently, laparoscopic gastrectomy for gastric cancer has been performed in many institutions, however, the adequacy of this procedure as standard-care is still controversial. It has been reported to have benefits such as a smaller wound, a smaller amount of intraoperative blood loss, and a shorter postoperative hospital stay (5).
Furthermore, laparoscopy enables a magnified view that makes it possible to determine the optimum dissected layer. Laparoscopic gastrectomy for RGC was first reported by Yamada et al. in 2005 (6).
Additional cases have been reported since then (5, 7, 10-16, Table IV), however, the availability and general versatility of this procedure for RGC is still unclear. We have performed four instances of laparoscopic surgery for RGC. Our four cases had distal gastrectomy performed previously involving different manners of reconstruction: Billroth I in two cases, Billroth II in one case, and Roux-en Y in one case. Herein we report these four cases of RGC that underwent laparoscopic gastrectomy in our Hospital and discuss the benefit of a laparoscopic approach for RGC and suggest that this may be an additional indication for laparoscopic surgery.
Case Report
The patients' background and previous surgeries are described in Table I. Details of their operation for RGC and their postoperative course are described in Table II and III, respectively. Intraoperative findings are detailed in the following text.
Case 1: Male, 83 years old. The patient had previously undergone distal gastrectomy for gastric cancer, with reconstruction by the Billroth-I method. During the operation, it was found that the transverse colon was widely knit together with the upper abdominal wound and the liver. The adhesion was sharply dissected using laparoscopic scissors without causing any bleeding. There was severe adhesion between the liver bed and the gastric remnant from the lesser curvature of the cardia to the gastro-duodenum anastomoses area. The local surgical field was well-visualized under high-vision laparoscopy. After determining the optimum dissection line between the liver and the gastric remnant, the adhesion was sharply dissected by laparoscopic scissors or an ultrasonically activated scalpel, with minimal bleeding from the liver (Figure 1A). In addition, severe adhesion was also found between the pancreas and the area of the gastro-duodenum anastomoses (Figure 1B). Under laparoscopic view, the adhesion was sharply dissected along the optimum dissection line. After total gastrectomy, reconstruction was performed using the Roux-en Y method in an ante-colic fashion. The next day after the total gastrectomy procedure, an emergency hemostatic operation had to be performed for intraperitoneal bleeding. The origin of the bleeding was the mesenteric artery of the jejunum. The patient had no trouble in the passing of stool afterwards.
Patients and previous operation.
Operations for remnant gastric cancer.
Postoperative course of laparoscopic total gastrectomy.
Case 2: Male, 78 years old. The patient had previously undergone distal gastrectomy for gastric cancer, with reconstruction by the Billroth-I method. The surgeons encountered similar adhesions as in case 1. Resection of the gastric remnant was performed similarly as for case 1. Reconstruction was performed using the Roux-en Y method in an ante-colic fashion. Esophago-jejunotomy was performed with double stapling technique using a trans-orally inserted anvil. The patient's postoperative course was uneventful.
Reported cases of laparoscopic gastrectomy for remnant gastric cancer.
Case 3: Male, 83 years old. The patient had previously undergone distal gastrectomy for duodenal ulcer, with reconstruction by the Billroth-II method through a retro-colic route. Intra-abdominal adhesion was mild compared to cases 1 and 2. In particular, adhesion around the lesser curvature of the gastric remnant was mild (Figure 1C). Firstly, the transverse mesocolon was spread out and the Treitz ligament identified. From the ligament, the jejunum was followed distally. After the jejunum was freed from the transverse mesocolon, an adhesion was found at the middle of the gastro-jejunostomy from the previous operation. The adhesion was sharply dissected with an ultrasonic coagulation device, with careful attention not to injure the intestinal canal. The jejunum was cut with a linear stapler at one centimeter proximal and distal from the gastro-jejuno anastomosis site, respectively. There was little adhesion around the upper stomach. After the gastric remnant was completely resected, Roux-en Y reconstruction was performed through a retro-colic route. The patient's postoperative course was uneventful.
Case 4: Male, 62 years old. The patient had previously undergone distal gastrectomy for gastric cancer, with reconstruction by the Roux-en Y method through a retro-colic route. During a postoperative follow-up gastroscopy, RGC (cT1N0M0, cStage IA) was found around the anastomoses. In this case, there was severe adhesion between the liver bed and the lesser curvature of the gastric remnant. In the process of adhesiotomy around this area, there was a moderate amount of bleeding from the liver. After the gastric remnant was completely resected, Roux-en Y reconstruction was performed through a retro-colic route. The patient's postoperative course was uneventful.
Discussion
Our four cases had distal gastrectomy performed previously involving different manners of reconstruction, Billroth-I in two cases, Billroth-II in one case, and Roux-en Y in one case (Table I). The adhesion area and the degree of adhesion were different in each case due to differences in the previous surgical technique. However, laparoscopic total gastrectomy for RGC was successfully performed in all four cases without conversion to open surgery. In cases 1 and 2, where distal gastrectomy with B-I reconstruction was previously performed, severe adhesion around the gastro-duodenum anastomoses was found. The magnified view from high-vision laparoscopy enabled the local surgical field to be well visualized, such that the optimum dissection line between the liver and the stomach could be identified and sharply dissected. The dissection of severe adhesion between the pancreas and the gastro-duodenum anastomoses area would be difficult under direct vision in open surgery because the adhesion was located dorsal to the gastric remnant. However, under laparoscopic view, it was possible to perform sharp dissection along the optimum dissection line. The adhesion was mild in case 3, possibly because his previous gastrectomy for duodenum ulcer was performed without lymph node dissection. There were no major postoperative complications such as anastomotic leak and pancreatic fistula.
A: The gastro-duodenal reconstruction was adhered to the left lobe of the liver in case 1. B: The posterior wall of the gastric remnant was severely adhered to the pancreas in case 1. C: The adhesion around the lesser curvature of the gastric remnant was mild in case 3.
Intraoperative blood loss was less than conventional open surgery (data not shown). In case 1, open hemostasis was performed one day after operation due to bleeding from a small mesenteric artery of the jejunum. In the first operation for RGC, the treatment of small mesenteric was performed under direct view in the process of making the ascending jejunum. The patient was on anti-coagulation treatment for chronic atrial fibrillation. Therefore, the primary cause of the bleeding might not have been due to the laparoscopic operation. Laparoscopic gastrectomy for early gastric cancer has been performed in many institutions and has become one of the most common operation methods in Japan. However, the expanded indication of laparoscopic gastrectomy for advanced gastric cancer, or aged patients is controversial. RGC is also an expanded indication for laparoscopic surgery. RGC is expected to increase along with the aging of society and progression of prognosis of primary gastric cancer. Among our four cases, two cases involved patients over the age of 80 years. Surgery for RGC was more invasive as compared to that for primary gastric cancer because of severe adhesion to surrounding organs as a result of past gastrectomy. Since the magnified view by laparoscopy makes it possible to recognize the optimum dissection layer, laparoscopic surgery might be more suitable than open surgery for RGC operations that require careful adhesiolysis.
In conclusion, laparoscopic surgery for RGC was performed safely in at least four cases where there was previous distal gastrectomy with different methods of reconstruction. Laparoscopic surgery could be a useful method with broad utility for RGC.
- Received April 22, 2015.
- Revision received May 22, 2015.
- Accepted May 25, 2015.
- Copyright© 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved
