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Page 2 of 10 Mazzola et al. Mini-invasive Surg 2019;3:12 I http://dx.doi.org/10.20517/2574-1225.2019.05

Keywords: Gastric cancer, totally laparoscopic total gastrectomy, mini-invasive treatment, total gastrectomy

INTRODUCTION
[1]
Gastric cancer is the second leading cause of cancer-related mortality worldwide . Although relevant
[2]
improvements in medical oncology, radical surgery still remains the mainstay of curative treatment .
Laparoscopic distal gastrectomy reached a wide diffusion in the last decades, before the treatment of
[3]
early gastric cancer, and then treating advanced gastric cancer too , especially in Eastern countries,
demonstrating clear advantages in terms of intraoperative bleeding, length of hospital stay, restoration of
[4]
bowel function and incidences of minor postoperative complications in comparison with open surgery .
Looking at these results, laparoscopic technique has been gradually adopted, including total gastrectomy,
[5]
confirming the short-term benefits as compared to open technique . On the other hand, laparoscopic
total gastrectomy is considered a very demanding procedure, due to the complexity of many steps like
omentectomy and lymphadenectomy; however the main reason of complexity is the technical difficulty of
[6]
esophago-jejunal reconstruction .
In order to overcome this complexity, many techniques have been proposed, ranging from hybrid
anastomosis by mini-laparotomy, to different kinds of totally laparoscopic ones using a circular or linear
[7]
stapler, without a clear superiority of one above the others . Furthermore the majority of data on this topic
[8]
comes from Eastern countries and from case series, making the debate still open . In this scenario, we
reported our experience of totally laparoscopic total gastrectomy.

METHODS
All consecutive patients who underwent laparoscopic total gastrectomy for gastric cancer with curative
intent, between January 2017 and June 2018 at our institution, were considered. Patients with esophago-
gastric junction cancer, with evidence of metastatic disease and/or underwent surgery with palliative intent
were excluded.

Exclusion criteria for laparoscopic treatment of gastric cancer were: tumor involvement of adjacent organs,
T4a tumor at endoscopic ultrasonography (EUS), tumor located in the greater curvature, preoperative
evidence of bulky lymph-nodes, anesthesiologic contraindications to pneumoperitoneum, history of other
surgery for gastric cancer, previous laparotomies for major upper abdominal surgery.

All the patients underwent preoperative complete workup consisting of esophago-gastro-duodenoscopy
with biopsy, gastric EUS, total body contrast-enhanced computed tomography (ce-CT). Tumor staging was
performed according to American Joint Committee on Cancer (AJCC) tumor/node/metastasis classification
[9]
and staging systems for gastric cancer 8th edition .

In all the patients with more than T2 N0 tumors, a perioperative chemotherapy was performed,
according to age, comorbidity and performance status and it was followed by a re-staging of the disease.
Complications were defined according to the Dindo-Clavien classification; severe complications were
[10]
considered those of grade > 2 . Data of the selected patients was retrieved from a prospectively collected
database; all the gathered data was recorded on an electronic spreadsheet and analysed using commercially
available software, SPSS 18.0 (IBM, Armonk, NY).

Perioperative management and technical details
All patients received low molecular weight heparin starting the evening before the surgery, 2 g cefazolin 15 min
before the skin incision, and 7-10 days preoperatively immunonutrition with 2 brick/day of impact oral.