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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 60-62

Laparoscopic total gastrectomy with D1+ lymph nodes dissection for a patient with early gastric cancer in Saudi Arabia


Department of Surgery, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

Date of Submission18-Dec-2018
Date of Acceptance21-Dec-2018
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Saeed Jaafar Alshomimi
Department of Surgery, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJL.SJL_11_18

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  Abstract 

Gastric cancer is not uncommon in Saudi Arabia and still one of the top causes of cancer-related deaths. Nevertheless, case reports and literature reviews regarding gastric cancer and its treatment options are rarely published in Saudi Arabia. Hence, we review the first case in Saudi Arabia of total laparoscopic gastrectomy accompanied by D1+ lymph node dissection done for a 55-year-old Saudi female with early gastric cancer (EGC). It was performed following the latest Japanese gastric cancer guidelines. The surgery was successful with neither intraoperative nor postoperative complications. In conclusion, laparoscopic treatment for EGC is a safe and feasible option for treatment in addition to faster recovery and less overall surgical complications on the short term compared with open gastric surgeries.

Keywords: Early gastric tumor, laparoscopic total gastrectomy, lymph node dissection


How to cite this article:
Aldubaisi SH, Alkhardawi SH, Alshomimi SJ, Abduljabbar AM. Laparoscopic total gastrectomy with D1+ lymph nodes dissection for a patient with early gastric cancer in Saudi Arabia. Saudi J Laparosc 2019;4:60-2

How to cite this URL:
Aldubaisi SH, Alkhardawi SH, Alshomimi SJ, Abduljabbar AM. Laparoscopic total gastrectomy with D1+ lymph nodes dissection for a patient with early gastric cancer in Saudi Arabia. Saudi J Laparosc [serial online] 2019 [cited 2019 Nov 15];4:60-2. Available from: http://www.saudijl.org/text.asp?2019/4/1/60/267854


  Introduction Top


Gastric cancer remains one of the leading causes of cancer-related deaths worldwide including Saudi Arabia.[1] As a result of its high prevalence and aggressive nature, many attempts were made throughout the years to develop more effective as well as less invasive methods for its management, beginning with laparoscopic surgery and moving toward endoscopic techniques. However, gastric cancer is yet hard to cure, and in many countries like Japan and Korea, where it is very prevalent, complete tumor resection with adjacent lymph nodes dissection remains the mainstay of treatment. In Saudi Arabia, due to the lack of gastric cancer screening, it is uncommon to diagnose and treat a patient with early gastric cancer (EGC). This report describes a case of EGC which was managed laparoscopically with total gastrectomy and D1+ lymph node dissection successfully following the Japanese guidelines.


  Case Presentation Top


We present a case of a 55-year-old Saudi female with chronic cholecystitis of 8 months duration. She underwent esophagogastroduodenoscopy (EGD), in which nothing significant other than gastric erythema was found. Furthermore, an endoscopist obtained multiple biopsies from different sites of the stomach, and the histopathology report revealed adenocarcinoma. EGD was repeated to confirm the site of the lesion, but it only revealed dysplasia, resulting in the decision of total gastrectomy. The patient was admitted for total laparoscopic gastrectomy abd D1+ lymph node dissection.

Intraoperatively, an 11-mm supraumbilical camera port was inserted after insufflation. Another two 12-mm ports at right and left paramedian, a 5-mm port at right midclavicular subcostal, and a 5-mm port at the left subxiphoid area were placed. Diagnostic laparoscopy was carried out, and neither liver or peritoneal deposits nor ascites were seen. However, an inflamed and distended gallbladder was noticed.

Left lobe of the liver retracted using double-sling technique. Harmonic scalpel was used to divide the gastrocolic ligament aiming to perform partial omentectomy with a 4-cm safety margin. The pyloroduodenal junction was dissected with ligation of the right gastroepiploic vessels and supra- and infra-pyloric lymph nodes dissection carried out (lymph node stations 2, 4sa, 4sb, 4d, 5, and 6). Transection was done at the level of the first part of the duodenum using echelon blue stapler [Figure 1] followed by dissection of the lymph node groups in the area of the lesser omentum (1 and 3) – finally, the perivascular lymph node (7, 8, 9, and 11b) was dissected [Figure 2] followed by gastric resection above the gastroesophageal junction after insertion of size 25 endoscopic intraluminal stapler end-to-end anastomosis (EEA) stapler anvil. A supraumbilical incision was extended and Alexis retraction ring was applied and the specimen extracted using endobag. The reconstruction was done using Roux-en-Y configuration leaving about a 60-cm distance from esophagojejunostomy and jejunojejunostomy. Methylene blue leak test was negative by the end of the procedure. Laparoscopic cholecystectomy was carried out at the same operation. Two Blake drains were placed in the subhepatic and epigastric to the left subdiaphragmatic areas and fixed with heavy silks.
Figure 1: Duodenal transection after clearance of infra- and supra-pyloric lymph nodes

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Figure 2: Perivascular lymph nodes dissection

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Five days postoperatively, gastrografin study was done and it showed no leak with smooth passage of the contrast [Figure 3], after which the patient was started on gradual feeding.
Figure 3: Postoperative contrast study demonstrate no leak after the surgery

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Histopathology revealed only a couple of tiny foci of well-differentiated tubular adenocarcinoma. The foci were not detected by gross examination; hence, they represent T1 tumors [Figure 4]. Twenty lymph nodes, omentum, and gallbladder were all free of metastasis.
Figure 4: High-power field microscopic view showing foci of well differentiated tubular adenocarcinoma

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The patient was discharged 11 days postoperatively with no complications.


  Discussion Top


The journey of laparoscopic gastric surgery started in 1992 in Singapore, when Goh et al. operated the first laparoscopic-assisted distal gastrectomy (LADG) for a chronic gastric ulcer.[2] In the same year, Kitano et al. performed LADG with D1+ α lymph node dissection for EGC.[3] A year later, Azagra et al. carried out the first laparoscopic total gastrectomy (LTG) for gastric cancer[4] ever since many successful laparoscopic gastric surgeries were reported, especially in Korea and Japan.

LADG gained popularity over open distal gastrectomy (ODG) due to its better short-term result.[5] However, long-term results are still controversial due to lack of evidence. Therefore, a multicenter, randomized controlled trial comparing LADG with ODG for EGC (KLASS-01) was established in Korea. The results proved the safety of the laparoscopic surgery as a minimally invasive procedure.[6] With the same purpose of KLASS-01 trial, another multicenter Phase II trial (JCOG 0703) was conducted in Japan to confirm the safety of LADG with D1+ nodal dissection for stage I gastric cancer. It showed that the proportion of patients who had either anastomotic leakage or a pancreatic fistula was equal to those who underwent ODG.[7] Moreover, a Phase III trial (JCOG0912) was done to confirm the noninferiority of LADG compared to ODG, and the results are expected to prove that LADG will become the gold standard method for distal gastric cancer.[8]

Regardless of the positive results of KLASS-01, LTG is not as accepted as LADG due to its surgical difficulty. Hence, a multicenter, prospective phase II trial (KLASS-03) for LTG for stage I gastric cancer was initiated to estimate the postoperative morbidity and mortality rates and to assess the surgical outcomes related to several reconstruction methods.[9]

Advanced gastric cancer (AGC) standard management is open gastrectomy with D2 lymphadenectomy according to the Japanese gastric cancer guidelines. The performance of D2 lymphadenectomy was correlated with lower local and regional recurrence rate compared to D1 lymphadenectomy. Thus, KLASS-02, a multicenter, randomized controlled phase III trial was established to estimate the 3-year survival rate after LDG and D2 lymphadenectomy for AGC and compare it with that of the open surgery.[10]


  Conclusion Top


The rapid advancement of laparoscopic instrumentation and surgical techniques used for lymph node dissection made it feasible to perform almost all types of gastrectomy with lymphadenectomy laparoscopically. However, to our knowledge, this is the first case of LTG for EGC published in Saudi Arabia despite the proven safety that is reported internationally.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to acknowledge Dr. Areej Alnemer, Pathology Department, Imam Abdulrahman Bin Faisal University, Saudi Arabia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Cancer Incidence Report Saudi Arabia 2013. Available from: https://nhic.gov.sa/eServices/Documents/2013.pdf. [Last accessed on 2019 Jan 10].  Back to cited text no. 1
    
2.
Goh P, Tekant Y, Kum CK, Isaac J, Shang NS. Totally intra-abdominal laparoscopic Billroth II gastrectomy. Surg Endosc 1992;6:160.  Back to cited text no. 2
    
3.
Kitano S, Iso Y, Moriyama M, Sugimachi K. Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc 1994;4:146-8.  Back to cited text no. 3
    
4.
Azagra JS, Goergen M, De Simone P, Ibañez-Aguirre J. Minimally invasive surgery for gastric cancer. Surg Endosc 1999;13:351-7.  Back to cited text no. 4
    
5.
Adachi Y, Shiraishi N, Shiromizu A, Bandoh T, Aramaki M, Kitano S, et al. Laparoscopy-assisted Billroth I gastrectomy compared with conventional open gastrectomy. Arch Surg 2000;135:806-10.  Back to cited text no. 5
    
6.
Kim HH, Han SU, Kim MC, Hyung WJ, Kim W, Lee HJ, et al. Prospective randomized controlled trial (phase III) to comparing laparoscopic distal gastrectomy with open distal gastrectomy for gastric adenocarcinoma (KLASS 01). J Korean Surg Soc 2013;84:123-30.  Back to cited text no. 6
    
7.
Katai H, Sasako M, Fukuda H, Nakamura K, Hiki N, Saka M, et al. Safety and feasibility of laparoscopy-assisted distal gastrectomy with suprapancreatic nodal dissection for clinical stage I gastric cancer: A multicenter phase II trial (JCOG 0703). Gastric Cancer 2010;13:238-44.  Back to cited text no. 7
    
8.
Nakamura K, Katai H, Mizusawa J, Yoshikawa T, Ando M, Terashima M, et al. A phase III study of laparoscopy-assisted versus open distal gastrectomy with nodal dissection for clinical stage IA/IB gastric cancer (JCOG0912). Jpn J Clin Oncol 2013;43:324-7.  Back to cited text no. 8
    
9.
Byun C, Han SU. Current status of randomized controlled trials for laparoscopic gastric surgery for gastric cancer in Korea. Asian J Endosc Surg 2015;8:130-8.  Back to cited text no. 9
    
10.
Kim HI, Hur H, Kim YN, Lee HJ, Kim MC, Han SU, et al. Standardization of D2 lymphadenectomy and surgical quality control (KLASS-02-QC): A prospective, observational, multicenter study [NCT01283893]. BMC Cancer 2014;14:209.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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