1、 Japanese Experience of Laparoscopic Oncologic Gastrectomy Nobuhiko Tanigawa, MD, FACS and Kyoichi Takaori, MD 0 0 200200 400400 600600 800800 10001000 12001200 14001400 9191 929293939494 9595 969697979898 999900000101 Total gastrectomy Proximal gastrectomy Distal gastrectomy (D2 or more) Distal gas

2、trectomy (D1+) Distal gastrectomy (D1) Local resection Intragastric surgery Miscellaneous 02020303 16001600 18001800 20002000 Distal gastrectomy (D1+) 0 0 200200 400400 600600 800800 10001000 12001200 14001400 9191 929293939494 9595 969697979898 999900000101 Total gastrectomy Proximal gastrectomy Di

3、stal gastrectomy (D2 or more) Distal gastrectomy (D1+) Distal gastrectomy (D1) Local resection Intragastric surgery Miscellaneous 02020303 16001600 18001800 20002000 Distal gastrectomy (D1+) Is lymph node dissection for early gastric cancer necessary ? 0.9 0.9 0.7 2.7 3.3 0.5 5.2 0.8 Percent inciden

4、ce of regional lymph node metastasis from T1(sm) cancer (L) 0.9 Group 1 nodes Group 2 nodes ( OMC experience in 1978 2000) 2.2 1.1 0.6 4.4 2.5 0.5 1.7 0.8 Percent incidence of regional lymph node metastasis from T1(sm) cancer (M) 0.3 2.7 0.9 Group 1 nodes Group 2 nodes ( OMC experience in 1978 2000)

5、 Is lymph node dissection for early gastric cancer necessary ? “Yes, it is.” N0 N1 N2 N3 T1(M) T1(SM) T2 T3 T4 H1, P1, CY1, M1, A EMR (Well diff., 2.) Gastrectomy with D2 A Gastrectomy with D2 B Extended Surgery Gastrectomy +D2 A Gastrectomy +D2 B Gastrectomy +D2 Extended Surg Palliative Surg Chemot

6、herapy Radiation ther Guidelines for Gastric Cancer Treatment (2001)： ： Recommendable Mode of Treatment defined by Disease Stage ( Standard Care, and N0 N1 N2 N3 T1(M) T1(SM) T2 T3 T4 H1, P1, CY1, M1, A EMR (Well diff., 2.0.) Gastrectomy with D2 ( 2.) Laparosopic gastrectomy Gastrectomy with D2 A Ga

7、strectomy with D2 B Extended Surgery Gastrectomy +D2 A Gastrectomy +D2 B Gastrectomy +D2 Extended Surg Palliative Surg Chemotherapy Radiation ther Guidelines for Gastric Cancer Treatment (2001)： ： Recommendable Mode of Treatment defined by Disease Stage ( Standard Care, and Investigational Treatment

8、) Advanced Cancer Strategy for GC Treatment Mucosal Cancer EMR Laparoscopic Surgery Open Surgery (OMC 2004) Submucosal Cancer Lap Gastrectomy for Early Cancer ( 1,622 cases in 21 leading institutions) Wedge Resection 96 (6%) Inragastric Resection 35 (2%) Total Gastrectomy 66(4%) Distal Gastrectomy 1

9、,218 (75%) Pylorus Preserving Gastrectomy 131 (8%) Proximal Gastrectomy 76 (5%) (Lap Study Group funded by Jp Ministry of Health, Welfare and Labor September, 2004) Complications in Japanese nationwide experience of lap-DG Stomal stenosis 103/2600 (3.9) Wound infection 45/ 2600 (1.7) Anastomotic lea

10、kage 43/ 2600 (1.6) Pancreatitis or fistula 17/ 2600 (0.6) Bleeding 13/ 2600 (0.5) Ileus 13/ 2600 (0.5) Peritoneal abscess 8/ 2600 (0.3) No. of Patients (%) 55 5 12 位置 Lymph node dissection around LGE vessels LGEV LGEV Lymph node dissection around RGE vessels GDA RGEA Lymph node dissection around RG

11、 vessels (from anterior aspect) Lymph node dissection around PHA PHA Lymph node dissection around CHA, LGA, SpA and CeA CHA Pancreas Lymph node dissection around SMV(14v) 當科Roux-Y再建手技 腹腔鏡下胃癌手術後腹壁傷腹腔鏡下胃癌手術後腹壁傷 Median Number of Retrieved Lymph Nodes, Blood Loss, and Operative Time in Open and Laparosc

12、opic Distal Gastrectomy Group 1 lymph nodes 21.7 20.0 Open-DG (n=394) Lap-DG (n=68) Group 2 lymph nodes 16.9 12.5 Blood loss (ml) 225 180 Operative time (min) 202 331 /total /38.6 /32.5 Conclusion-LDG in general n With recent advent of instrumentation, laparoscopic approach is increasingly applied for patients with early cancer. n Proper extent of lymph node dissection for early cancer appears feasible with keeping lower incidence of morbidity. However, oncologic adequacy of lymph node dissection is not proved at present. Is lymph node dissection for earl