A totally laparoscopic distal gastrectomy
with gastroduodenostomy (TLDG)for improvement of the early surgical outcomes in high BMI patients
Min Gyu Kim •Hironori Kawada •Beom Su Kim •
Tae Hwan Kim •Kap Choong Kim •Jeong Hwan Yook •Byung Sik Kim
Received:4May 2010/Accepted:7August 2010/Published online:11September 2010ÓSpringer Science+Business Media,LLC 2010
Abstract
Objective To evaluate the effectiveness of totally lapa-roscopic distal gastrectomy with gastroduodenostomy (TLDG),we compared its early surgical outcomes with tho of laparoscopy-assisted distal gastrectomy with gas-troduodenostomy (LADG).
Methods We retrospectively analyzed early surgical out-comes in 567patients who underwent laparoscopic gas-trectomy for gastric cancer between January 2009and March 2010.The patients w
ere divided into tho with underwent TLDG and tho with underwent LADG.Their surgical outcomes were analyzed according to the WHO Asia–Pacific Obesity classification.
Results In overall patients,TLDG showed the significant results of early surgical outcomes.But more importantly,in the analysis of early surgical outcomes for obe patients,we found that TLDG could improve overall complication rate (p =0.031),time to first flatus (p =0.009),time to commencement of soft diet (p \0.001),administration of analgesics (p =0.019),pain score (Numeric Rating Scale,NRS),and hospital discharge (p =0.003).
Conclusions We suggested that TLDG contributes to the improvement of early surgical outcomes.We further sug-gest that TLDG in obe patients could be the best way to improve early surgical outcomes,including the bowel
movement,pain score,overall complication rate,and hospital discharge.
Keywords Laparoscopy-assisted distal gastrectomy ÁTotally laparoscopic distal gastrectomy
Laparoscopic gastrectomy has become a promising method of surgical treatment for patients who were diagnod with early gastric cancer (EGC),with many advantages over open gastrectomy,inclu
ding cosmetic effect,less pain,earlier recovery,shorter hospital stay,and better quality-of-life [1–12].Since the first description of laparoscopy-assisted distal gastrectomy with gastroduodenostomy (LADG)for EGC in 1994[13],there have been veral reports on early surgical outcomes of totally laparoscopic distal gastrectomy with gastroduodenostomy (TLDG)[14–17].In the studies,although TLDG has been shown to be safe and feasible for EGC,it has not yet been directly compared with the early surgical outcomes of laparoscopy-assisted gastrectomy.Therefore,to evaluate the advantages of TLDG,we com-pared early surgical outcomes in patients who underwent TLDG and LADG at our institution.
Materials and methods
Patients
recycle是什么意思
We retrospectively reviewed the prospectively collected data on 567concutive patients who underwent laparo-scopic gastrectomy,including LADG and TLDG,for gas-tric cancer between January 2009and March 2010at single institution.All patients in whom the remnant stomach was too small to perform gastroduodenostomy had laparoscopic
M.G.Kim ÁH.Kawada ÁB.S.Kim ÁT.H.Kim ÁK.C.Kim ÁJ.H.Yook ÁB.S.Kim
Department of Gastric Surgery,University of Ulsan College of Medicine and Asan Medical Center,Seoul,Republic of Korea B.S.Kim (&)
校园演讲稿Division of Gastric Surgery,Department of Surgery,
Asan Medical Center,Ulsan University,Pungnap 2-dong,Songpa-gu,Seoul,Republic of Korea e-mail:bskim@amc.oul.kr
Surg Endosc (2011)25:1076–1082DOI
10.1007/s00464-010-1319-0
distal gastrectomy with Roux-en-Y reconstruction,and the patients were excluded in this study.Our patient population consisted of 328who underwent LADG and 239who underwent TLDG.With regard to obesity,182patients were defined as obe patients according to the WHO Asia–Pacific Obesity classification (body mass index (BMI)[25).
Three experts participated in this comparative study.By 2008,three experts had experienced for 500,
400,and 200cas of laparoscopic gastrectomy,respectively.Two of three experts had performed totally laparoscopic gastrec-tomy.Three experts standardized all procedures of lapa-roscopic gastrectomy and critical pathway of postoperative management.The methods of laparoscopic gastrectomy had been decided by the lection of patients.Surgical techniques
Each patient was placed in the rever Trendelenburg position.A carbon dioxide pneumoperitoneum was formed from the umbilical port,and pressure was maintained between 12and 15mmHg.Five trocars were placed in a U-shape (Fig.1).The falciform ligament was fixed to the anterior wall of the peritoneum for retraction of the liver using ENDO CLOSE TM .If the operating field was not sufficient,an additional 5-mm trocar was inrted into the epigastric area to retract the liver.
Disction was begun by dividing the greater omentum from the mid-portion of the gastroepiploic arcade to the left gastroepiploic vesl.The lymph nodes around the left
gastroepiploic vesls were discted,depending on the location of the primary tumor.After disction of the lymph nodes around the right gastroepiploic area,the infrapyloric area was discted.In some patients,disc-tion was advanced to the superior menteric vein to include enlarged 14v lymph nodes.Lymph nodes around the suprapyloric area;hepatoduodenal ligament (alo
ng the hepatic artery);common hepatic,proximal splenic,celiac,and left gastric arteries;and right paracardial and lesr curvature areas were discted in that order.
In procedures of LADG,after clearing the lymph nodes,a 4–5-cm midline incision was made from the epigastric trocar site.A wound protector was applied,and gastrodu-odenostomy was reconstructed using a circular stapler (PROXIMATE ÒILS;DST Series TM EEA TM ).
In procedures of TLDG,duodenal stump is made after clearing of number 5lymph nodes and mobilization of duodenum.The duodenum is trancted just below duo-denal bulb using an endoscopic linear stapler (ENDO-PATH ÒETS45).The tranction line was positioned in the ventrodorsal direction.To make ventrodorsal direction of duodenum,the operator turned the stomach in clockwi direction.First assistant inrted endoscopic linear stapler through left lower port to make the duodenal stump.After clearing of all lymph nodes,the stapler was introduced through the left lower port,and transaction of stomach was performed by first assistant.The specimens were removed through the umbilical port by extending the incision as the I-shaped incision.To remake pneumoperitoneum,we had four or five interrupted sutures in umbilical port and tied the sutures leaving two sutures.The small opening of the greater curvature side of the remnant stomach and the posterior side of the duodenal stump was made by endo-scopic scissor.To make V-shaped anastomosis of posterior walls,the first assistant inrted the stapler on small opening of remnant stomach and pulled the stapler line of remnant stomach at an angle of 45degrees.Then,the operator guided so that the first assistant could inrt the stapler on the duodenal opening.Before firing,the operator pulled the stapler line of duodenal stump at an angle of 45degrees (Fig.2).Finally,the anterior hole was clod with the stapler [14].Clinical analysis
Clinical data obtained from medical records included patient age,gender,BMI,and ASA score.Early surgical outcomes included operative time,postoperative transfusion rate,overall and major complications (except for wound problems),time to first flatus,day of commencement on soft diet,number of administrations of analgesics,Numeric Rating Scale (NRS),and postoperative hospital stay.Path-ologic results were analyzed for tumor size,number
of
Fig.1Trocar placements for totally laparoscopic distal gastrectomy.Op operator,F.A.first assistant,Sc scopist,S.N.scrub nur
retrieved lymph nodes,rection margins,and UICC/AJCC staging.
Our postoperative pain control consisted of intravenous patient-controlled analgesia (IV PCA:Fentanyl 2500l g,Ketorolac tromethamine 180mg,Ondantron HCl 16mg).To evaluate the patients’postoperative pain,we calculated the number of additional dos of analgesics until the patient was discharged from the hospital.Also,we applied the NRS for all patients.The Numeric Rating Scale was checked on postoperative day (POD)0,POD (ante meridiem)(post meridiem),POD ,POD ,and POD The NRS scores of POD 0were c
hecked 6h later after surgery to minimize bias of pain degree.
Patients were discharged if they had no problems eating a soft diet,showed an abnce of inflammatory conditions,including leukocytosis,unstable vital sign,and abrupt ont abdominal pain,and were generally comfortable.Also,we left the final decision about discharge up to the patients.Statistical analysis
Statistical analysis was performed using SPSS version 12.0for Windows (SPSS,Inc,Chicago,IL).Groups were compared using the chi-squared test or one-way analysis of variance with post hoc comparison (Turkey’s test),depending on the data.A p value \0.05was considered statistically significant.
Results
Patient demographics
The clinical characteristics of the 567patients are pre-nted in Table 1.In comparison for overall patients,there
was no difference in age,gender,and ASA score,except for the high BMI of TLDG group (TLDG:24.0,
LADG:23.1;p \0.001).The other asssment of subgroups showed the similar results in obe patients (Table 1).Early surgical outcomes of laparoscopic gastrectomy Table 2prents early surgical outcomes in overall patients.In operation time,it took more time to perform TLDG than LADG (p \0.001).There were no significant differences for overall and major complications (p =0.166,p =0.702).The mean day to first flatus (p \0.001)and commencement of soft diet (p \0.001)were checked earlier in the TLDG group than in the LADG group.The postoperative hospital stay was significantly shorter in the TLDG group than in the LADG group (p =0.005).NRS scores were significantly lower in the TLDG group than in the LADG group at POD 0,POD ,POD 2,and POD 3(p =0.003,p =0.001,p =0.012,p =0.002).
Table 3prents early surgical outcomes in subgroups.Especially in obe patients,there were pronounced dif-ferences statistically for surgical outcomes compared with tho of underweight and nonobe patients.The overall complication rate in the TLDG group was significantly lower than in the LADG group (p =0.031).The mean day to first flatus (p =0.009)and commencement of soft diet (p \0.001)were checked earlier in the TLDG group than in the LADG group.The postoperative hospital stay was significantly shorter in the TLDG group than in the LADG group (p =0.003).NRS scores were significantly lower in the TLDG group at POD 0,POD ,POD ,POD ,POD ,and POD (p =0.001,p =0.004,p =0.002,p =0.030,p =0.001,p =0.002).
Table 4prents postoperative complications in overall and obe patients.In obe patients,overall complication rate was higher in the LADG group than in the TLDG group.Especially,many wound complications occurred in the LADG group.
In pathologic results,there was significant difference of the distribution of tumor depths (p =0.001).As a result,it showed marginal significance (p =0.088)that the rate of lymph node metastasis was higher in the TLDG group (Table 5).
Discussion
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Since its introduction in 1994,LADG has become an increasingly popular method for the surgical treatment of patients with EGC [13].Recently,many surgeons have described their experiences with totally laparoscopic gas-trectomy and suggested the feasibility and safety of
this
Fig.2Before firing endoscopic linear stapler,operator pulled the duodenal stump at the direction of operator (gray arrow )and first assistant pulled the remnant stomach at the direction of him (white arrow )
procedure [14–17].However,there have been no investi-gations of its effectiveness compared with tho of LADG.We therefore evaluated the ufulness of TLDG by com-paring it with LADG using the high volume.
In the prent study for patients’demographics,there was significant difference in mean BMI.Although the decision of LADG or TLDG resides with patient,this difference may come from favored explanation of TLDG in high BMI patients.Several studies have reported that the early surgical outcomes of laparoscopic gastrectomy,except for operation time,were unrelated to patient’s BMI [18,19].We believe that the higher BMI had no effect on favored early surgical outcomes of the TLDG group,becau the mean BMI was higher in the TLDG group than in the LADG group.
In practical procedures,TLDG and LADG differ in many respects.First,TLDG utilizes a different recon-struction method,performed via a laparoscopic procedure using endoscopic linear staplers.Th
e intracorporeal reconstruction using endoscopic linear staplers may form an anastomosis without forceful tension,leading to injuries
T a b l e 1C l i n i c a l c h a r a c t e r i s t i c s o f p a t i e n t s i n t h e L A D G a n d T L D G g r o u p s
V a r i a b l e s
O v e r a l l p a t i e n t s (n =567)
U n d e r w e i g h t \18.5k g /m 2(n =57)
N o n o b e s e 18.5–25.0k g /m 2(n =328)
O b e s e [25.0k g /m 2(n =182)
L A D G (n =328)
T L D G (n =239)
p v a l u e L A D G (n =32)
T L D G (n =25)
p v a l u e L A D G (n =211)
T L D G (n =117)
p v a l u e L A D G (n =85)
T L D G (n =97)
p v a l u e
M a l e /f e m a l e r a t i o
198/130
155/84
0.276
18/14
12/13
0.536
127/84
70/47
0.949
53/32
73/24
0.06
A g e (y r )
55.4±11.2
56.6±12
51.2±14.655.4±14.4
0.278
56.2±11.1
57.5±12.4
0.338
55±9.8
55.8±11
0.59
A S A s c o r e
0.145
0.396
0.301
0.569
A S A 1
215
138
孟晓驷2315
139
67
53
56
A S A 2
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100879
9
61
42
30
36
A S A 3
13140
1
11
8
2
5
B M I (k g /m 2)
23.1±2.7
24±3.2
\0.00117.8±0.6
18±0.3
0.19722.6±1.3
22.8±1.40.14226.5±1.5
27.1±1.60.021
V a l u e s a r e e x p r e s s e d a s m e a n s ±s t a n d a r d d e v i a t i o n s u n l e s s o t h e r w i s e i n d i c a t e d
B M I b o d y m a s s i n d e x ,L A D G l a p a r o s c o p y -a s s i s t e d d i s t a l g a s t r e c t o m y ,T L D G t o t a l l y l a p a r o s c o p i c d i s t a l g a s t r e c t o m y w i t h g a s t r o d u o d e n o s t o m y
Table 2Early surgical outcomes in overall patients who underwent LADG and TLDG Variables
scotty mccreery
LADG (n =328)
TLDG (n =239)
p value
Operation time (min)104.2±22.7132.1±26.8\0.001Length of incision (cm)
5.1±0.3
2±0.1\0.001Overall complications (no.of patients,%)
21(6.4%)9(3.8%)0.166Major complications (no.of patients,%)
10(3%)6(2.5%)0.702Postoperative transfusion 14(4.3%)7(2.9%)0.404Time to first flatus (days ±SD)
3.2±0.73±0.7\0.001Time to commencement of soft diet (days ±SD)4±1.1 3.6±1.2\0.001No.of administration of analgesics 2.8±2.5
2.5±2.1
0.09
NRS score
POD 0(at 6h after surgery) 4.2±1.7 3.7±1.70.003POD 3.4±1.63±1.30.001POD 2.8±1.5 2.7±1.20.205POD 2.7±1.5 2.4±1.40.012POD 2.2±1.2 1.9±1.10.002POD
1.1±1.11±10.08Postoperative hospital stay (days ±SD)
6.9±1.8 6.5±1.4
0.005
Data are means ±standard deviations or numbers (percentages)unless otherwi indicated
LADG laparoscopy-assisted distal gastrectomy,TLDG totally lapa-roscopic distal gastrectomy with gastroduodenostomy,POD postop-erative day
to the structures around the anastomosis.Second,there was no manipulation of operationfield for all procedures. Moreover,TLDG have a sufficiency of small incision (2-cm extension of the umbilical port)for removing the specimen compared with LADG.The smaller incisions would be less traumatic and less invasive[7,15,16,20].
We found that the early surgical outcomes were more favorable for obe patients who underwent TLDG,as assd by overall complications,earlier bowel move-ment,less pain during recovery,and earlier hospital dis-charge.We speculate that the differences resulted from the demerits of LADG procedures in obe patients.In
Table3Early surgical outcomes in the underweight,nonobe,and obe groups
Variables Underweight
BMI\18.5kg/m2Nonobe
BMI18.5–25kg/m2
Obe
BMI[25kg/m2
LADG (n=32)TLDG
(n=25)
p value LADG
(n=211)
TLDG
(n=117)
p value LADG
(n=85)
TLDG
(n=97)
p value
Operation time(min)97.7±23.8117.5±21.90.002103.1±22.5124.9±23.8\0.001109.6±21.8144.6±26.4\0.001 Length of incision(cm)5±0.22±0.1\0.0015±0.12±0.1\0.001 5.3±0.52±0.2\0.001 Overall complications1(3.1%)1(4%)0.8599(4.3%)4(3.4%)0.70711(12.9%)4(4.1%)0.031 Major complications1(3.1%)1(4%)0.8594(1.9%)2(1.7%)0.9045(5.9%)3(3.1%)0.360 Postoperative transfusion1(3.1%)2(8%)0.41310(4.7%)4(3.4%)0.5713(3.5%)1(1%)0.251 Time tofirstflatus
(days±SD)newyorktimes
遇见比尔3.2±0.6 3.0±0.60.407 3.3±0.7 3.1(±0.7)0.046 3.2±0.8 2.9(±0.7)0.009
Time to commencement of
soft diet(days±SD)
3.9±0.6 3.7(±0.9)0.4394±1.1 3.6(±1.2)0.002
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4.2±1.3 3.5(±1.0)\0.001
No.of administration of
analgesics
2.6±2.8
3.2(±2.4)0.381 2.7±2.3 2.3(±2.3)0.220 3.4±2.9 2.5(±1.8)0.019
POD0(at6h after
surgery)
3.5±1 3.2(±1.3)0.3244±1.6 3.6(±1.7)0.0815±2
4.0(±1.8)0.001 3.4±1.9 2.8±1.40.160 3.3±1.6 2.9±1.20.032 3.8±1.5 3.2±1.30.004 2.4±1 2.6±1.20.509 2.7±1.6 2.7±1.30.938 3.3±1.2 2.7±1.20.002 2.3±1.1 2.3±1.50.947 2.6±1.5 2.5±1.40.454 3.1±1.5 2.3±1.30.030 2.3±1.32±1.20.342 2.1±1.2 1.9±1.20.211 2.4±1.3 1.8±1.10.001 1.4±1.11±0.90.2751±1.11±10.994 1.5±1.11±10.002 Postoperative hospital stay
(days±SD)
6.9±2.6 6.9±2.40.938 6.8±1.7 6.5±1.30.068
7.2±1.8 6.4±1.40.003
Data are means±standard deviations or number of patients(percentages)unless otherwi indicated
LADG laparoscopy-assisted distal gastrectomy,TLDG totally laparoscopic distal gastrectomy with gastroduodenostomy,POD postoperative day, BMI body mass index
Table4Lists of postoperative morbidities in overall and obe patients
Overall patients Obe patients
LADG (n=328)TLDG读书报告怎么写
(n=239)
p value LADG
(n=85)
TLDG
(n=97)
p value
Overall complications(no.of patients2190.1661140.031 Major complications1060.702530.36 Anastomosis leakage2111
Anastomosis stenosis10
Anastomosis bleeding21
Extra-luminal bleeding11
Intra-abdominal abscess4342
Wound complications11261
Paralytic ileus01
LADG laparoscopy-assisted distal gastrectomy,TLDG totally laparoscopic distal gastrectomy with gastroduodenostomy
