1. Blair A. Jobe, MD Professor of Surgery University of Pittsburgh Pittsburgh, Pennsylvania

2. Chronology Laparoscopic distal gastrectomy was introduced in 1994 by Japanese surgeons (Kitano S). Laparoscopic total gastrectomy was reported in 1995 Reasons for a slow acceptance Complexity of the procedure Oncological adequacy R0 “en bloc” resection Subtotal gastrectomy (distal cancer) Total gastrectomy (proximal, medial or multifocal cancer) Appropiate lymph node harvesting Subsequent reconstruction of the alimentary tract

3. Lymphnodeinvolvement 10-20% N+ in earlygastric cancer >60% N+ in invasive gastric cancer >T3 20-30% of patient with non earlygastric cancer have microscopicmetastases in the para-aorticnodes (japanasesserieswithextendedlymphadenectomy)

4. D1 Japaneselymphnode dissection 2 1 4 3 3 4 4 4 5 6 D1: 1-6 7 910 11 8a D2: D1+7-11 12 14 13 D3: D2+12-14 15 16 D4: D3+15,16 8p

5. Second Japanese Classification

6. 1 Right paracardial 2 Leftparacardial 3 Lessercurvature 4sa Short gastricvessels 4sb leftgastroepiploic 4d right gastrepiploic 5 Suprapyloric 6 Infrapyloric 7 Leftgastricartery 8a Common Hepaticarteryant. 8p Common hepaticartery Post 9 Celiacartery 10 Splenichilum 11p Proximal splenicartery 11d Distal splenicartery 12a Hepaticartery 12b Along the bile duct 12p Behind the portal vein 13 Retropancreatichead 14v Superior mesentericvein 14a Superior mesentericartery 15Middle colicvessels 16 Around abdominal aorta 17 Anteriorpancreatishead 18 Inferiormagin of the pancreas

7. 19 Infra diaphragmatic 20 Oesophagel hiatus 110 paraesophageal in the lower thorax 111 Supradiaphragmatic 112 Posteriormediastinal

8. L/M/ULOWER DISTALMIDDLE PARTUPPER 11211 21M31 31111 4sa1M31 4sb1311 4d1112 51113 61113 72222 8a2222 8b3333 92222 102M32 11p2222 11d2M32 12a2223 12 bp2333 13333M 14v223M LMULDMU 14aMMMM 15MMMM 16a1MMMM 16a2, b13333 16b2MMMM 17MMMM 18MMMM 193MM3 203MM3 110MMMM 111MMMM 112MMMM

9. LymphadenectomyBased on PrimaryTumor Location D0: no or incomplete dissection of Group 1 D1: Dissection of all the group 1 nodes D2: Dissection of all the groups 1 and 2 nodes D3: Dissection of all the groups 1, 2 and 3 nodes

10. D1 vs D2 lymphnode dissection in non japaneseseries Dent Cape Town Trial Hong Kong Trial Bonenkamp Dutch Trial Cuschieri MRC trial Wu Taiwan Trial D1 VS D3 1988199492/95/ 99/0496 / 9904/06 D1/D221 / 2025/30380 / 331200 / 200110/111 Morbidity0% / 27%0% / 46%25% / 43%28% / 48%7.3% /17.1%* Mortality0% / 0%4% / 10%6.5% / 13%0% / 0% Survival78% / 76% 3y 30% / 35% 11y 35% / 33% 5 y 53.6% / 59.5%* Extendedlymphadenectomyenhaces more precisestaging Significantlyhighermorbidityafter D2 dissection withoutimprovement in survival

11. 14 trials (3432 patients) D1 vs D2StudiesD1D2 Op mortality83.6%7.1%.001 Post op morbidity825.5%44.3%0.0001 3y survival456.3%51.3%NS 5y survival648.7%49.7%NS D2 vs D3 Op mortality52.3%2.2%NS Post op morbidity524.7%29.6%NS D2 and D3 lymphadenectomyfor gastric cancerdoes not demonstrate advantages in postoperative survival. Yang SH. Am J Surg 2009

12. Extended lymph node dissection for gastric cancer: Results of the randomized Dutch gastric cancer group trial Extended lymph node dissection generated no long- term survival benefit Higher postoperative mortality offsets its long-term effect in survival M and Mare greatly influenced by the extent of lymph node dissection, pancreatectomy, splenectomy and age Hartgrink H et al. J Clin Oncol 2004

13. Extended vs limitedlymphnodedissection - Meta–analysis 2 RCT (MRC and Dutch trials) Possible risks and possible benefits of D2 should be consideredunproven. D2 dissection is an acceptable procedure in the hands ofsurgeonsthat can demonstrate lowoperativemortality. D2 could be considered the preferred treatment for fit patients with intermediate stage (II to III) gastric cancer D1 dissection should be preferred inpoor surgical candidates and very early cancer. Cochrane Database 2003

14. D2 vs extended para-aorticlymphadenectomy Japaneses RCT Japan Clin Oncol Group Sano D2/ Extended263 / 259 Total gastrectomy102 / 97 Splenectomy98 / 93 Pancreatectomy9 / 13 Mean op time (min)237 / 300* Meanbloodloss (ml)430 / 660* No of retrievednodes54 / 74* Overallmorbidity20.9% / 28.1% Re-op1.0% / 2.7% Mortality0.9% / 0.9% LOS (days)21 / 24* Sano T. J Clin Oncol 2004

15. D2 vs extended para-aorticlymphadenectomy Japaneses RCT: Survival The 5-year overall survival rate wassame for both groups Treatmentwith D2 lymphadenectomyplus PAND does not improve survival Japan Clin Oncol Group tumor size (cm)5.5 / 5.5 Upper and middle K59.4% / 57.7% P T2b-T479% / 80.3% N+70% / 63.1% R10.8% / 0% Morbidity Diarrhea,lymphorrhea 20.9% 28.1%* 9.1% 20%* 5y survival if N-78.4% / 96.8% 5y survival if N+65.2% / 54.9% Sasako M. New Engl J Med 2008

16. Meta-analysis Open vs Lap distal gastrectomy 4 RCT including 162 distal gastrectomy (Lap 81 / Op 80) Lapbetterthan Open Blood loss (357.1 ml vs 258 ml) (-104ml)* Lapworsethan Open Operative time (186.6 min vs 268.3 min) (+83min)* Lymphnodeharvested ( 32.1 vs 28.5) (-4.3)* Lap = open Hospitalstay (16.1 d vs 12.1d) Mortality (2.5% vs 1.2%) Morbidity rate (35% vs 25%) Tumorrecurrence (12.5% vs 13.4%) Time to oral intake (6 d vs 4.9 d) Memon MA. SurgEndosc 2008

17. Improved Quality of Life Outcomes After Laparoscopy-Assisted Distal Gastrectomy for Early Gastric Cancer 2003-2005LADGOpenP 82 Meanage (y)56.754.5 Mean op time (min)2521700.001 Meanbloodloss (ml)1112670.001 Morbidity0%4.8% Mortality Lenght of incision (cm)6.119.30.05 Meanlymphnode39450.003 Time to liquiddiet4.54.90.0001 Hospitalstay (d)7.28.60.0001 Analgesicinfused (ml)39.447.80.01 Kim YW Ann Surg 2008

18. Improved Quality of Life Outcomes After Laparoscopy-Assisted Distal Gastrectomy for Early Gastric Cancer Pain, appetite loss, and quality of sleep resulted in higher scores in the LADG group compared with the ODG group. Opengroup had more dysphagia, pain, dietary restriction, and dry mouth at days 7, 30 and 90 LADG better for emotional change, reflux and body image Kim YW Ann Surg 2008

19. Laparoscopy-assisted total gastrectomy for gastric cancer: A multicenterretrospectiveanalysis 1485 lap- assistedgastrectomy 1998-2005 VariableValue% Tumor location (Sup/mid/low)76/48/5/258/37/4/1 Depth of tumor (T1/T2/T3)90/30/1169/23/8 Lympnode(N0/N1/N2/N3)104/21/4/279/16/3/2 Mean op time (min)269 Conversion1/131 Anastomosis Extra corporeal Intra corporeal Jejunalinterpositionl 115 8 89 6 Lymphnoderetrieved34.7

20. Laparoscopy-assisted total gastrectomy for gastric cancer: A multicenterretrospectiveanalysis VariableValue% Time to firstintake (d)5.8 Postopmorbidity2519 Leakage32.3 Post op mortality0 LOS (d)11.3 5y cumulativesurvival89% 5ydisease free survival94% Recurrence rate86 Jeong GA. Surgery 2009

21. Reconstruction Subtotal gastrectomy Totallylaparoscopicga stroduodenostomy(Bil lroth I) Billroth I throughminilaparoto my Billroth I with hand port Roux-en-Y Gastrojejunostomy

22. Reconstruction after total gastrectomy Roux-en-Y esophagojejunostomy Hand-sewnanastomosis Laparoscopic Mini-laparotomy Mechanicalanastomosis Circularstapler Manuallyloadanvil Transoral (Orivil)

23. Reconstruction after total gastrectomy Omori T et al. Am J Surg 2009

24. Technical Considerations

25. Conclusion Oncologicgastricresectionisfeasibleunderlaparoscopyby experienced surgeons and in selectedpatients Laparoscopic D1 resectionis a reasonableapproach to gastricmalignancy Asianseries have reported an equivalentsurvivalbetweenlaparoscopic and open gastrectomy Level 1 trials are lacking in Western countries to demonstratean unquestionableadvantage of the laparoscopicapproach over the open approach