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Page 6 of 10 Mazzola et al. Mini-invasive Surg 2019;3:12 I http://dx.doi.org/10.20517/2574-1225.2019.05

Table 1. Patients’ characteristics
Number of patients 10
Sex ratio (M/F) 6/4
Age (year)* 76 (60-93)
2
BMI (kg/m )* 24 (19-32)
ASA score 1/2/3 1/6/3
clinical T1/T2/T3 # 1/2/7
clinical EGC/AGC ratio 1/9
clinical N0/N+ # 3/7
clinical stage I/IIa/IIb/III # 1/2/2/5
Preoperative CT 4

#
Data are expressed as number of patients. *Data is expressed as an average with the range in brackets; clinical staging according AJCC
8th Edition. Pts: patients; M: males; F: females; BMI: body mass index; ASA: American Society of Anaesthesiologists; EGC: early gastric
cancer; AGC: advanced gastric cancer; CT: chemotherapy

gastrectomy with D2 lymphadenectomy and 4 of these had received preoperative chemotherapy; in 2 cases
the lymphadenectomy of the station 10 was performed. Demographic and preoperative features of these
patients are reported in Table 1. After an uneventful resective phase in all patients, 1 of these received E-J
anastomosis using HDS technique with transorally inserted anvil, 5 received S-S overlap anastomosis and
4 underwent E-S anastomosis. Only one patient experienced intraoperative complications; the only case
reported was related to an esophageal injury during S-S E-J anastomosis needing the only conversion to
laparotomy of the series; after conversion an E-S E-J anastomosis with a hand-sewn purse-string was done
without further complications; other intraoperative details are reported in Table 2. Although no 30 day
fatal events occurred, 7 patients experienced postoperative complications, 3 of these were severe according
[10]
to Dindo-Clavien classification ; they consisted of ileus due to internal hernia, and abdominal abscess
in splenic fossa needing reoperation; the last one was the only E-J anastomotic leakage and occurred in a
patient who underwent laparoscopic E-S anastomosis and treated with endoscopic transanastomotic stent
positioning. At pathological examination all the specimens had free proximal resection margins and all
the patients received R0 resection; average numbers of harvested lymph-nodes was 29. Clinical staging
was confirmed in 5 patients; on the other hand, 2 patients were under-staged and 3 over-staged; this miss-
staging didn’t affect the curative intent of surgery and no peritoneal carcinosis was detected at laparoscopy.

Average postoperative length of hospital stay was 10 days and no patients died during hospitalization. With
a minimum follow-up of 6 months, median overall survival (OS) and disease-free survival (DFS) were 15.5
and 12.5 months respectively. All the patients included in perioperative chemotherapy program were able
to complete the post operative treatment. Postoperative outcomes are described in Table 3.

DISCUSSION
Laparoscopic surgery is a valid option for the treatment of gastric cancer; although only the minor part of
the data about it comes from randomized clinical trials (RCTs) [13,14] . A large number of results from non
RCTs and case series assessed its safety and feasibility [4,15] , however the majority of the reported data refers
to distal gastrectomy and only a few parts of the ongoing RCTs include total gastrectomy [17-19] .
[16]

Nevertheless it gained wide diffusion in Eastern countries, with a slow adoption in Europe and USA
too [11,20] , showing less blood loss, fewer analgesic uses, earlier passage of flatus, quicker resumption of oral
intake, earlier hospital discharge, and reduced postoperative morbidity, with longer operative time, in
[5]
comparison with open total gastrectomy . Our data, obtained from a non selected series of European older
adults, was consistent with these evidences, reporting 3 cases of severe adverse events, 2 of these requiring
reoperation; 1 of these was due to an internal hernia and since that occurance we always have sutured the
jejunal mesentery without occurance of further cases.