Skip to content

Advertisement

  • Case Report
  • Open Access

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

  • 1,
  • 1, 2Email author,
  • 1,
  • 1,
  • 1,
  • 1,
  • 1,
  • 1, 3 and
  • 1
Surgical Case Reports20195:63

https://doi.org/10.1186/s40792-019-0610-0

  • Received: 5 November 2018
  • Accepted: 21 March 2019
  • Published:

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.

Keywords

  • Remnant gastric cancer
  • Laparoscopic completion gastrectomy
  • Elderly patients

Background

In the Japan Clinical Oncology Group (JCOG) 0912 trial, laparoscopic surgery (LS) for treating early-stage gastric cancer was shown to be a feasible procedure in terms of adverse events and short-term clinical outcomes [1]. Currently, LS has been established as a standard treatment [2]. In addition, the LS safety profile in distal gastrectomy with D2 lymphadenectomy for advanced gastric cancer is comparable to that reported for open surgery (OS) regarding postoperative morbidity and mortality rates [3].

For remnant gastric cancer (RGC), the surgical resection is indicated in numerous cases [4] and open completion gastrectomy (OCG) is ordinarily selected due to severe adhesions and difficulty recognizing the anatomical orientation after primary gastrectomy. On the other hand, as LS has been developed for gastric cancer, there is increasing evidence that the laparoscopic completion gastrectomy (LCG) can be a therapeutic option for RGC [5]. Moreover, we conducted a study at Saiseikai Yokohamashi Tobu Hospital showing the safety and the efficacy of LCG [6].

Elderly peoples require special consideration due to the decline in physical, physiological, and social functions [7]. Thus, a careful and safe surgical approach in elderly patients (EPs) is required. Two meta-analyses revealed LS advantages for treating EPs with gastric cancer in terms of early recovery and fewer complications [8, 9]. However, there are limited studies investigating the use of LS for the treatment of RGC in EPs.

In the present study, we reviewed RGC patients assigned to either the LCG or the OCG group over a 10-year period. Evaluating short- and long-term outcome, we aim to assess the efficacy of LCG in treating EPs.

Case presentation

Patients and methods

We retrospectively reviewed 21 patients aged ≥ 70 years who underwent completion gastrectomy for RGC between April 2007 and October 2017 at Saiseikai Yokohamashi Tobu Hospital. The patients were 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 [10]. Since the score for one question pertaining to the self-perception of health was not obtained, the total score was calculated based on the remaining seven questions. In all patients, the clinical stage was evaluated according to the Japanese Classification of Gastric Carcinoma [11]. Postoperative complications were categorized using the Clavien–Dindo classification (C-D) [12]. In this study, complications classified as C-D grade ≥ II were considered postoperative complications. Patient characteristics, clinicopathological characteristics, surgical outcome, and survival were retrospectively reviewed and compared between the LCG and the OCG groups.

Both surgical approaches were presented to the patients, and either OCG or LCG was selected based on their preferences and their surgeons’ recommendations. All surgeries were performed by board-certified surgeons (Japan Surgical Society), and all LCG were performed by TE, who is a qualified surgeon according to the Endoscopic Surgical Skill Qualification System.

Surgical procedures

LCG and OCG with splenic preservation were conducted. Reconstruction was performed using the Roux-en-Y (R-Y) method. In LCG, patients under general anesthesia were placed in the reverse Trendelenburg position with the legs slightly apart. The surgeon stood on the patient’s left side, with an assistant on the right and another assistant holding a laparoscope between the legs. An initial 12-mm trocar was inserted at the umbilicus through the open method. Reviewing the abdominal cavity, we checked whether there were adhesions to the abdominal wall. In cases with previous LS, other ports were placed at the previous port wound (5 mm on the subcostal region and 12 mm on the abdomen bilaterally) (Fig. 1). A flexible electrolaparoscope was used, and the CO2 pressure was maintained at 10 mmHg.
Fig. 1
Fig. 1

The placement of surgical ports

The remnant stomach was completely mobilized by dissecting the adhesion between the remnant stomach and the left lateral segment of the liver, as well as the one between the remnant stomach and the pancreas. For patients in whom primary surgery was performed for benign disease, the supra pancreatic lymph nodes were resected in addition to those around the remnant stomach. The reconstruction was performed using the R-Y method through the pre-colon route. Esophagojejunostomy was performed using the overlap technique in the LCG group [13].

Statistical analysis

Statistical analysis was performed using R version 3.5.1 (The R Foundation for Statistical Computing, Vienna, Austria). Demographic and surgical data were compared between the LCG and OCG groups. Continuous variables were analyzed using the Mann–Whitney U test. Categorical data were compared using Fisher’s exact probability test or the chi-squared test. Patient survival was calculated using the Kaplan–Meier method, and the significance of differences between the curves was analyzed using the log-rank test. A p < 0.05 denoted statistical significance in all analyses.

Results

Preoperative evaluation using the G8 geriatric screening tool

Using the G8 geriatric screening tool, we retrospectively evaluated the patients’ physical, mental, and social conditions. The answers to the individual questions are provided in Table 1. Two patients had lost > 3 kg of weight in the OCG group, whereas those in the LCG group tended to show a lower body mass index without statistical significance. Overall, there was no significant difference in the individual scores, resulting in total scores of 12.5 and 13.0 for the LCG and OCG groups, respectively (p = 0.841).
Table 1

Preoperative evaluation using the G-8 geriatric screening tool

Items (possible answers: score)

LCG, n = 6

OCG, n = 15

p

Decrease in food intake in the past 3 months

  

0.159

 Severe: 0

0

0

 Moderate: 1

0

4 (27%)

 No decrease: 2

6 (100%)

11 (73%)

Weight loss in the past 3 months

  

0.347

 > 3 kg: 0

0

2 (13%)

 Does not know: 1

0

0

 Between 1 and 3 kg: 2

0

0

 No weight loss: 3

6 (100%)

13 (87%)

Mobility

  

0.105

 Bed or chair bound: 0

0

0

 Able to get out of bed and chair but does not go out: 1

1 (17%)

0

 Goes out: 2

5 (83%)

15 (100%)

Neuropsychological problems

  

0.516

 Severe dementia or depression: 0

0

0

 Mild dementia or depression: 1

0

1 (7%)

 No mental problems: 2

6 (100%)

14 (93%)

Body mass index

  

0.182

 < 19: 0

2 (33%)

1 (7%)

 19–21: 1

2 (33%)

5 (33%)

 21–23: 2

0

6 (40%)

 > 23: 3

2 (33%)

3 (20%)

More than three prescribed medications

  

0.576

 Yes: 0

2 (33%)

7 (47%)

 No: 1

4 (67%)

8 (53%)

Self-perception of health

 Not as good: 0

  

 Does not know: 0.5

  

 As good: 1

  

 Better: 2

  

Age

  

0.125

 > 85: 0

1 (17%)

0

 80–85: 1

2 (33%)

2 (13%)

 < 80: 2

3 (50%)

13 (87%)

Modified score (median, range)

12.5, 11.3–13.8

13.0, 12.0–13.5

0.841

LCG laparoscopic completion gastrectomy, OCG open completion gastrectomy

Preoperative patient characteristics

Comparisons of preoperative patient characteristics between the two groups are shown in Table 2. The proportion of males and patients who underwent OS as initial gastrectomy were significantly higher in the OCG group (p = 0.014 and p = 0.022, respectively). There were no differences between the two groups in terms of previous disease and reconstruction procedure. In addition, there was no significant difference in the time interval between the previous gastrectomy and the completion gastrectomy (p = 0.907).
Table 2

Preoperative patient characteristics

 

LCG

n = 6

OCG

n = 15

p

Sex

  

0.014

 Male

2 (33%)

13 (87%)

 Female

4 (67%)

2 (13%)

ASA-PS class

  

0.526

 I

4 (67%)

8 (53%)

 II

1 (17%)

1 (7%)

 III

1 (17%)

6 (40%)

 IV

0

0

 V

0

0

ECOG-PS

  

0.105

 0

1 (17%)

0

 1

5 (83%)

15 (100%)

 2

0

0

 3

0

0

Original disease

  

0.291

 Malignant

4 (67%)

13 (87%)

 Benign

2 (33%)

2 (13%)

Previous approach

  

0.022

 Open

3 (50%)

14 (93%)

 Laparoscopic

3 (50%)

1 (7%)

Previous reconstruction

  

0.844

 B-I

4 (67%)

8 (53%)

 B-II

1 (17%)

4 (27%)

 R-Y

1 (17%)

3 (20%)

Time interval (years; median, range)

15.5, 2.3–37.8

7.0, 3.5–28.0

0.907

LCG laparoscopic completion gastrectomy, OCG open completion gastrectomy, ASA-PS American Society of Anesthetists-physical status, ECOG-PS Eastern Cooperative Oncology Group performance status, B-I Billroth-I reconstruction, B-II Billroth-II reconstruction, R-Y Roux-en-Y reconstruction

Pathological findings, surgical outcomes, and postoperative course

In terms of surgical outcomes (Table 3), blood loss was significantly lower in the LCG group versus the OCG group [median (range); LCG, 50 ml (20.0–65.0); OCG, 465 ml (264.5–714.0); p = 0.002]. There was no significant difference in operative time between the two groups (p = 0.791). Due to the severe adhesion between the abdominal wall and small intestine, the laparoscopic approach was converted to the open approach in one patient from the LCG group who had undergone open gastrectomy with Billroth-I reconstruction for gastric cancer as primary surgery. The median number of retrieved lymph nodes in the LCG group was 7 (range 4–10) versus 3 (range 1–6) in the OCG group (p = 0.171). The LCG and OCG did not differ with respect to the distribution of TNM stages. Furthermore, there were no statistically significant differences in postoperative hospitalization (p = 0.410), intake of solid food (p = 0.867), and the occurrence of C-D grade ≥ II postoperative complications (p = 0.477). Thirty days after surgery, there was no reported perioperative mortality in either group.
Table 3

Pathological findings, surgical outcomes, and postoperative course

 

LCG

n = 6

OCG

n = 15

p

Operative time (min; median, range)

310.5, 249.5–337.8

263.0, 241.5–325.0

0.791

Blood loss (ml; median, range)

50, 20.0–65.0

465, 264.5–714.0

0.002

Open conversion, n (%)

1 (17%)

0

0.105

Number of retrieved LNs (median, range)

7, 4–10

3, 1–6

0.171

pT

  

0.869

 T1

2 (33%)

5 (33%)

 T2

0

0

 T3

1 (17%)

4 (26%)

 T4

3 (50%)

6 (40%)

pN

  

0.642

 N0

6 (100%)

13 (87%)

 N1

0

1 (7%)

 N2

0

1 (7%)

 N3

0

0

pM

  

0.347

 M0

6 (100%)

13 (87%)

 M1

0

2 (13%)

pStage

  

0.562

 IA

2 (33%)

5 (33%)

 IB

0

0

 IIA

1 17%)

3 (20%)

 IIB

0

0

 IIIA

3 (50%)

3 (20%)

 IIIB

0

0

 IIIC

0

2 (13%)

 IV

0

2 (13%)

Postoperative hospitalization (days; median, range)

9, 7.3–13.8

9, 8.5–17.5

0.410

Intake of solid food (days; median, range)

4, 3.3–4.0

3, 3.0–4.0

0.867

Postoperative complication (C-D grade ≥ II)

3 (50%)

5 (33%)

0.477

Mortality within 30 days after surgery

0

0

LCG laparoscopic completion gastrectomy, OCG open completion gastrectomy, LN lymph node, C-D Clavien–Dindo

Survival after completion gastrectomy

In this study, the median follow-up period was 21 months, and the 5-year overall survival rate was 80.0% versus 60.6% in the LCG and OCG groups, respectively (p = 0.683, Fig. 2). Of the six deaths which occurred during the follow-up period, five were attributed to gastric cancer recurrence (one and four deaths, respectively). The remaining death was attributed to other diseases.
Fig. 2
Fig. 2

Overall survival. There was no significant difference in overall survival between the LCG and OCG groups. LCG laparoscopic completion gastrectomy, OCG open completion gastrectomy

Comparison of the modified G8 geriatric screening tool score in patients with or without postoperative complications

We evaluated the correlation between the modified G8 geriatric screening tool score and the occurrence of postoperative complications. The analysis showed that there was no significant difference in the modified G8 geriatric screening tool scores between patients with and without postoperative complications (p = 0.654, Table 4).
Table 4

Comparison of the modified G8 geriatric screening tool scores in patients with or without postoperative complications

 

Postoperative complication (C-D grade ≥ II)

p

Present (n = 8)

None (n = 13)

Modified G8 geriatric screening tool score (median, range)

13, 11.0–14.0

13, 12.8–13.3

0.654

C-D Clavien–Dindo

Comparison of the postoperative modified G8 geriatric screening tool score among the patients who did not exhibit postoperative recurrence

We also evaluated the role of G8 geriatric screening score 1 year after surgery. Based on the review of the clinical records, we could evaluate the scores of nine patients, including three and six patients in the LCG and OCG groups, respectively, among the 17 patients who did not exhibit postoperative recurrence. We found that there were no significant differences in any of the factors including the total score [median (range); LCG, 8.0 (7.5–8.5); OCG, 10.5 (8.3–12.8); p = 0.362].

Surgical outcome in LCG patients with a history of gastrectomy for gastric cancer as primary surgery

In the LCG group, two of the four patients with a history of gastrectomy for gastric cancer underwent D2 lymph node dissection as primary surgery. As shown in Table 5, operative time tended to be longer in patients with D2 gastrectomy [median (range); D2, 352.0 min (349.0–355.0); D1 or D1+, 251.8 min (271.5–292.3); p = 0.333].
Table 5

Surgical outcomes in patients with the history of gastrectomy for gastric cancer as primary surgery in the LCG group

Lymphadenectomy for primary surgery

D2 (n = 2)

D1+/D1 (n = 2)

p

Operative time (min; median, range)

352.0, 349.0–355.0

271.5, 250.8–292.3

0.333

Blood loss (ml; median, range)

30, 20–40

190, 130–250

0.333

Open conversion, n (%)

0

1 (50%)

0.248

Postoperative hospitalization (days; median, range)

9, 8.5–9.5

12, 9.5–14.5

1

Intake of solid food (days; median, range)

4.0, 4.0–4.0

2.5, 2.4–2.8

0.221

Postoperative complication (C-D grade ≥ II)

1 (50%)

0

0.248

Mortality within 30 days after surgery

0

0

C-D Clavien–Dindo

Discussion

There was no significant difference in the preoperative modified G8 geriatric screening tool score, indicating that the EPs’ backgrounds in each group were comparable. Blood loss during surgery was significantly reduced in the LCG group. In addition, there was no significant difference in oncological outcomes (e.g., the number of dissected lymph nodes) and prognosis. Overall, we demonstrated that LCG was shown to be applicable for treating EPs aged ≥ 70 years.

A standard surgical treatment for RGC has not been established. In terms of the indication of splenectomy, total gastrectomy without splenectomy was shown to be non-inferior to the one without splenectomy in treating proximal advanced gastric cancer without the lesions on the greater curvature in the JCOG 0110 trial [14]. However, because the lymphatic network is altered following primary surgery for RGC [15], the results of the JCOG 0110 trial are not applicable to treating RGC. Moreover, primary gastrectomy may influence completion gastrectomy, including severe adhesion development. Therefore, OCG has been preferable for treating RGC. The present study was consistent with this paradigm; OCG was frequently selected for patients who had undergone OS as primary surgery (Table 2).

Ohira recommended endoscopic surveillance after distal gastrectomy and detection RGC at an early stage. Moreover, the minimally invasive approach of endoscopic submucosal dissection and LCG may provide patients with an improved quality of life [4]. Currently, five studies comparing LCG and OCG in RGC patients have been reported [5, 1619]. These studies have shown LCG is safe and effective for treating RGC, including reduced blood loss, increased number of dissected lymph nodes, shorter time to first flatus, and lower complication rate. Consistent with these results, we recently reported the advantages of LCG over OCG [6].

Elderly peoples’ physiological reserves gradually decrease. Moreover, elderly peoples’ cases are characterized by multiple complicating factors such as frailty and comorbidities [7]. Consequently, EPs experience more postoperative complications after abdominal surgery [20]. Therefore, minimally invasive and enhanced recovery approaches are warranted for treating EPs. In the current analysis, LCG was associated with reduced blood loss, versus OCG, without extending operative time. This finding demonstrated the favorable safety profile in LCG. Furthermore, there was no significant difference in oncological outcomes and prognosis between the LCG and OCG groups. On the other hand, in the LCG group, the operation time tended to be longer in patients who had D2 lymph node dissection for gastric cancer as primary surgery. Especially for elderly patients, the physiopathological implications of laparoscopy including prolonged operation time should be carefully considered [21]. Therefore, LCG needs to be cautiously selected in patients who underwent D2 lymph node dissection for gastric cancer as primary surgery.

The present study was limited to retrospective assessments. To minimize bias in patient recruitment, we reviewed consecutive EPs who underwent completion gastrectomy at Saiseikai Yokohamashi Tobu Hospital. Another limitation of this study is that the surgical approach was selected based on patient preference and surgeons’ recommendations. However, the retrospective evaluation, using the modified G8 geriatric screening tool score, confirmed no significant differences between the two groups (Table 1), indicating they were comparable in terms of vulnerability.

Conclusions

LCG was shown to be comparable to OCG for treating RGC in patients aged ≥ 70 years. Furthermore, blood loss during surgery was significantly reduced in LCG versus OCG. 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.

Abbreviations

C-D: 

Clavien–Dindo

EPs: 

Elderly patients

JCOG: 

Japan Clinical Oncology Group

LCG: 

Laparoscopic completion gastrectomy

LS: 

Laparoscopic surgery

OCG: 

Open completion gastrectomy

OS: 

Open surgery

RGC: 

Remnant gastric cancer

R-Y: 

Roux-en-Y

Declarations

Funding

We declare that each author received no funding for this study.

Availability of data and materials

The datasets supporting the conclusions of this article are included within the article and its additional files.

Authors’ contributions

MK and SM drafted the manuscript. SM participated in treating the patients and revised the manuscript. SM, EB, KM, AN, and TE performed the surgery. FS, HK, and JT participated in the surgery and postoperative management. All authors read and approved the final manuscript.

Ethics approval and consent to participate

All procedures were in accordance with the ethical standards of the responsible committees on human experimentation (institutional and national).

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors’ Affiliations

(1)
Department of Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1, Shimosueyoshi, Tsurumi-ku, Yokohama-shi Kanagawa, 230-8765, Japan
(2)
Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
(3)
Department of Surgery, Saiseikai Kanagawaken Hospital, 6-6, Tomiya-chou, Kanagawa-ku, Yokohama-shi Kanagawa, 221-0821, Japan

References

  1. Katai H, Mizusawa J, Katayama H, Takagi M, Yoshikawa T, Fukagawa T, et al. Short-term surgical outcomes from a phase III study of laparoscopy-assisted versus open distal gastrectomy with nodal dissection for clinical stage IA/IB gastric cancer: Japan Clinical Oncology Group Study JCOG0912. Gastric Cancer. 2017;20:699–708.View ArticlePubMedGoogle Scholar
  2. Japanese Gastric Cancer A. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer. 2017;20:1–19.View ArticleGoogle Scholar
  3. Hu Y, Huang C, Sun Y, Su X, Cao H, Hu J, et al. Morbidity and mortality of laparoscopic versus open D2 distal gastrectomy for advanced gastric cancer: a randomized controlled trial. J Clin Oncol. 2016;34:1350–7.View ArticlePubMedGoogle Scholar
  4. Ohira M, Toyokawa T, Sakurai K, Kubo N, Tanaka H, Muguruma K, et al. Current status in remnant gastric cancer after distal gastrectomy. World J Gastroenterol. 2016;22:2424–33.View ArticlePubMedPubMed CentralGoogle Scholar
  5. Tsunoda S, Okabe H, Tanaka E, Hisamori S, Harigai M, Murakami K, et al. Laparoscopic gastrectomy for remnant gastric cancer: a comprehensive review and case series. Gastric Cancer. 2016;19:287–92.View ArticlePubMedGoogle Scholar
  6. Booka E, Kaihara M, Mihara K, Nishiya S, Handa K, Ito Y, et al. Laparoscopic total gastrectomy for remnant gastric cancer: a single-institution experience. Asian J Endosc Surg. 2018.Google Scholar
  7. Evers BM, Townsend CM Jr, Thompson JC. Organ physiology of aging. Surg Clin North Am. 1994;74:23–39.View ArticlePubMedGoogle Scholar
  8. Wang JF, Zhang SZ, Zhang NY, Wu ZY, Feng JY, Ying LP, et al. Laparoscopic gastrectomy versus open gastrectomy for elderly patients with gastric cancer: a systematic review and meta-analysis. World J Surg Oncol. 2016;14:90.View ArticlePubMedPubMed CentralGoogle Scholar
  9. Zong L, Wu A, Wang W, Deng J, Aikou S, Yamashita H, et al. Feasibility of laparoscopic gastrectomy for elderly gastric cancer patients: meta-analysis of non-randomized controlled studies. Oncotarget. 2017;8:51878–87.PubMedPubMed CentralGoogle Scholar
  10. Bellera CA, Rainfray M, Mathoulin-Pelissier S, Mertens C, Delva F, Fonck M, et al. Screening older cancer patients: first evaluation of the G-8 geriatric screening tool. Ann Oncol. 2012;23:2166–72.View ArticleGoogle Scholar
  11. Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer. 2011;14:101–12.Google Scholar
  12. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13.View ArticlePubMedPubMed CentralGoogle Scholar
  13. Morimoto M, Kitagami H, Hayakawa T, Tanaka M, Matsuo Y, Takeyama H. The overlap method is a safe and feasible for esophagojejunostomy after laparoscopic-assisted total gastrectomy. World J Surg Oncol. 2014;12:392.View ArticlePubMedPubMed CentralGoogle Scholar
  14. Sano T, Sasako M, Mizusawa J, Yamamoto S, Katai H, Yoshikawa T, et al. Randomized controlled trial to evaluate splenectomy in total gastrectomy for proximal gastric carcinoma. Ann Surg. 2017;265:277–83.View ArticlePubMedGoogle Scholar
  15. Son SY, Kong SH, Ahn HS, Park YS, Ahn SH, Suh YS, et al. The value of N staging with the positive lymph node ratio, and splenectomy, for remnant gastric cancer: a multicenter retrospective study. J Surg Oncol. 2017;116:884–93.View ArticlePubMedGoogle Scholar
  16. Son SY, Lee CM, Jung DH, Lee JH, Ahn SH, Park DJ, et al. Laparoscopic completion total gastrectomy for remnant gastric cancer: a single-institution experience. Gastric Cancer. 2015;18:177–82.View ArticlePubMedGoogle Scholar
  17. Kim HS, Kim BS, Lee IS, Lee S, Yook JH, Kim BS. Laparoscopic gastrectomy in patients with previous gastrectomy for gastric cancer: a report of 17 cases. Surg Laparosc Endosc Percutan Tech. 2014;24:177–82.View ArticlePubMedGoogle Scholar
  18. Kwon IG, Cho I, Guner A, Kim HI, Noh SH, Hyung WJ. Minimally invasive surgery as a treatment option for gastric cancer in the elderly: comparison with open surgery for patients 80 years and older. Surg Endosc. 2015;29:2321–30.View ArticlePubMedGoogle Scholar
  19. Nagai E, Nakata K, Ohuchida K, Miyasaka Y, Shimizu S, Tanaka M. Laparoscopic total gastrectomy for remnant gastric cancer: feasibility study. Surg Endosc. 2014;28:289–96.View ArticlePubMedGoogle Scholar
  20. Polanczyk CA, Marcantonio E, Goldman L, Rohde LE, Orav J, Mangione CM, et al. Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery. Ann Intern Med. 2001;134:637–43.View ArticlePubMedGoogle Scholar
  21. Caglia P, Tracia A, Buffone A, Amodeo L, Tracia L, Amodeo C, et al. Physiopathology and clinical considerations of laparoscopic surgery in the elderly. Int J Surg. 2016;33(Suppl 1):S97–S102.View ArticlePubMedGoogle Scholar

Copyright

© The Author(s). 2019

Advertisement