| Background and PurposeGastric cancer remains one of the most common gastrointestinal malignant. The incidence and morbidity of gastric cancer remain both the third rank in all of the malignant tumors in China. Ohgami et al reported the first case of laparoscopic wedge gastrectomy(LWG) in 1994 for early gastic cancer. Kitano et al first applied and described laparoscopy-assisted distal gastrectomy(LADG) as treatment for early gastric cancer(EGC) in the same year. In Japan, a total of 7,800 laparoscopic gastrectomies had been performed between 1991 and 2003 According to the reserch of Korean Laparoscopic Gastrointestinal Surgery Study Group,1,089 patients underwent laparoscopic gastric surgery in 2004. Laparscopic gastrectomy has become the standard procedure for early gastric cancer up to now.We successfully performed laparoscopic-assisted wedge gastrectomy for gastrointestinal stromal tumours(GIST) and early gastric cancer(EGC) in Sir Run Run Shaw Hospital in 2003. We performed laparoscopy-assisted gastrectomy (LAG) for advanced gastric cancer(AGC) from Nov.2004, and concluded that laparoscopy-assisted gastrectomy with lymph node dissection is possible to the same extent as open gastrectomy.The research team performed the first totally laparoscopic gastrectomy in March 2007,and until December 2009,45 totally laparoscopic gastrectomy for gastric cancer have been successfully performed in Sir Run Run Shaw Hospital. This paper retrospectively analyze the clinical data of these 45 cases in order to investigate the feasibility, safety, advantage, operative difficulties and skill of this procedure.Methods1. Object:Retrospectively analyze the 45 gastric cancer patients' clinical data who were diagnosed as gastric cancer by gastroduodenoscope with biopsy and underwent totally laparoscopic gastrectomy in Sir Run Run Shaw Hospital from Mar 2007 to Dec 2009.2. Measures:①Common data:gender, age, height, body weight, chief complain and pre-operation examination results.②Operative data:type of procedure, operation time and blood loss.③Pathological data:retrieved lymph nodes number, positive lymph nodes number, location of tumor, tumor size, length of proximal margin to tumor, length of distal margin to tumor, pathological classification, TMN staging(according to UICC,1997).④Post-operation data:post-operation complication, first flatus time, first soft meal diet and postoperative hospital stay.3. Statistic:All the data were reviewed and statistically analyzed using SPSS 11.5. We calculate the mean and standard deviation, and the outcome is presented withχ±s.Results1.General results:A total of 45 cases were analyzed in this research.The patient group included 38 men,17 women with an average age of 58.1±12.1 years(range from 34 to 77 years).The average BMI was 22.4±3.1 kg/m2 (rang from 18.2～32.8 kg/m2), with 11 patient over 25kg/m2. The clinical symptoms included abdominal pain in 34 cases, melena in 6 cases, acid reflux in 1 cases and 4 case was found incidentally. Seven patients combined with hypertension, six patient combined with diabetes mellitus, one patient combined with emphysema and one patient combined with chronic bronchitis. Ten patient had histories of previous abdominal sugery,including cholecystectomy(2 cases), appendectomy(5 cases), hysterectomy(1 case), cesarean section(1 case) and open distal gastrectomy(1 case). All patients were preoperatively diagnosed by endoscopic biopsy as gastric cancer, except one case of gastric lymphoma.2. Operation results:A number of 45 patients underwent totally laparoscopic gastrectomy successfully, including totally laparoscopic distal gastrectomy (TLDG) for 36 cases, totally laparoscopic total gastrectomy (TLTG) for 8 cases. Among the all patients, the types of Billroth- reconstruction were performed in all totally laparoscopic distal gastrectomy and Roux-en-Y gastrojejunostomy in all totally laparoscopic total gastrectomy, which contained 5 end-to-side esophagojejunostomy and 3 side-to-side esophagojejunostomy. There was one case of totally laparoscopic remnant gastrectomy(the patient who had open distal gastrectomy 6 years before, and Roux-en-Y reconstitution was performed),the remnant intestinal was raised to the esophagus after dissected the intestine below the original gastrojejunostomy, and Roux-en-Y gastrojejunostomy was performed again. In order to obtain a safe proximal resection margin, intraoperative gastroscopy was performed in 21 patients. The average operative time was 300.0±79.1 min (range between 155 min to 435 min). The average blood loss was 208.3±137.1 ml (range between 50 ml to 600 ml).3. pathologic diagnosis:The location of tumor included cardia (4 case), body(5 case), sinus(36 case);lesser curvature of stomach (41 cases),greater curvature of stomach(4 cases). The mean number of total retrieved lymph nodes was 29.9±8.2 (range from 18 to 55), and the median number was 28. Except for 1 case of IIIA stage with positive margin (Mass located at the sinus of lesser curvature, about 10.5cm×6.0cm in size, intraoperative pathology showed proximal margin positive, and the family member refused to performed extended radical operation),the remaining cases were all with negative margin. The average length of proximal margin to the tumor was 5.1±2.1cm(rang from 3.0 to 7.5 cm), and the average length of distal margin to the tumor was 6.4±1.9cm(rang from 5.1 to 11.0 cm). The pathological diagnosis included well-differentiated adenocarcinoma(8 cases), moderately-differentiated adenocarcino-ma(8 cases), poorly-differentiated adenocarcinoma(l case), undifferentiated adenocar-cinoma (1 case), signet-ring cell carcinoma(7 cases), mucinous adenocarcinoma(l case), papillary adenocarcinoma(2 cases), B cell lymphoma(1 case), high-grade intraepithelial neoplasia(3 cases). The TNM staging included stage IA 2 cases, stage IB 10 cases, stageⅡ26 cases, stageⅢA 5 cases, stageⅢB 2 cases(UICC,1997).4. Postoperative recovery results:The average time of the first flatus time was 3.8±1.1 days(range from 2d to 7d). The average time of liquid diet was 5.4±2.1 days(range from 2d to 17d). The average postoperative hospital stay was 9.08±3.3 days(range from 6d to 21d, with the median time 10d). Postoperative complications occurred in six patients (11.1%). There were two cases of delayed gastric empting. Both of them recovered well with conservative management after 6 days and 21 days. There were two cases of pulmonary infection. One of them had emphysema before, and the other had 40 years smoking history, with chronic cough and expectoration several years. Both of them recovered well with conservative management after 9 days and 10 days. There was one case of lung embolism 2 days after operation, and was transfered to Respiratory Medicine for anticoagulant therapy for 21 days. without anastomotic leakage and postoperative mortality occurred.5. Postoperative follow-up:The average follow-up period was 15 months (range 2-33 Months),3 cases lost follow-up, and the follow-up rate was 93.3%. Twenty-three patients underwent chemotherapy post-operation. One patient of IIIB stage was found the right ovary metastasis 4 months post-operatively, and bilateral adnexectomy was performed. The right side of the rectum and the bottom of pelvic metastasis was found 12 months post-operatively, and the patient required to go back local hospital for comprehensive treatment. She was still alive with 13'months follow-up. One patient of I B stage was found ileocecal junction mass because of intestinal obstruction 13 months post-operatively, and ileostomy was performed. The patient is still alive until now. One patient of IIIA stage was found intestinal obstruction 10 months post-operatively, and colon by-pass operation was performed, the patient was still alive until now too. There were no more recurrence case and postoperative mortality occurred.ConclusionTotally laparoscopic gastrectomy for gastric cancer is a safe, feasible procedure. Preliminary studies have shown that TLG has the advantages of less blooding, less invasive and faster postoperative recovery.
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