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Laparoscopic assisted gastrectomy:updating.

Romeo Giuli MD, resident.
School of General and Emergency Surgery.
University of Siena.   Italy.

November 2002.     Review Article.

To the first article
To the third article
To the fourth article

The absolute indications for EMR accepted by the Japanese Gastroenterological Endoscopy Society are histologically well or moderately differentiated mucosal carcinomas of elevated type and < 20 mm in diameter, or depressed type without ulceration and < 10 mm in diameter. In addition, the indications for EMR were extended to carcinomas 30 mm at some institutions with successful results because the prevalence of lymph node metastases with mucosal cancers < 30 mm in diameter without histologic ulceration or lymphatic permeation is extremely low (0.36%). Recent advances in EMR with an insulated-tip electrosurgical knife have made it possible to achieve en-bloc resections of much larger early-stage gastric cancers with a reduction in the recurrence rate and to resolve the conventional difficulty with tumor location in the proximal body and posterior wall of the stomach.
Wedge resection and intragastric surgical procedures are rapidly being overtaken by these newly developed endoscopic techniques for treating mucosal cancers. Mucosal cancers located at a site inadequate for EMR were treated by laparoscopic local resection (wedge resection or intragastric surgical procedures). Intragastric surgical procedures were selected for cancers on the posterior wall and wedge resection for those on the anterior wall ( 1, 2 ).
Although laparoscopic wedge resection has become less important in the cancer treatment, it should be the first option for SMT( submucosal tumors ). Cheng and colleagues, Aogi and associates, and Choi and Oh found that laparoscopic wedge resection was less invasive than open surgical procedures, as shown by faster postoperative recovery, and that it was also safe with fewer complications. But it was not indicated when the tumor was located near the cardia or pylorus where the esophago-cardial junction or pyloric ring could be involved in the resection line. When the tumor was too large to prevent gastric stenosis after wedge resection, LADG was used instead ( 1, 3, 4, 5, 6 ) .
The technique of LADG with lymph node dissection, developed by Kitano and colleagues and Nagai and associates, should be used for patients with lesions beyond the indications for EMR. These indications include intramucosal cancers with ulceration or poor differentiation and early carcinomas with submucosal invasion. The less invasive nature of LADG compared with open surgical techniques has been demonstrated in several reports showing faster postoperative recovery and better quality of life after LADG ( 1, 7, 8, 9 ).
The curability of the disease is of the utmost importance, and the extent of lymph node dissection must be carefully evaluated in LADG ( 1, 10, 11, 12, 13 ).


1) Shuji Shimizu, Hirokazu Noshiro, Eishi Nagai, Akihiko Uchiyama, Masao Tanaka. Laparoscopic Gastric Surgery in a Japanese Institution: Analysis of the Initial 100 Procedures. J Am Coll Surg 2003;197:372-378. Abstract

2) Miyamoto S, Muto M, Hamamoto Y, et al. A new technique for endoscopic mucosal resection with an insulated-tip electrosurgical knife improves the completeness of resection of intramucosal gastric neoplasms. Gastrointest Endosc 2002;55:576-581. Pub Med

3) Cheng HL, Lee WJ, Lai IR, et al. Laparoscopic wedge resection of benign gastric tumor. Hepatogastroenterology 1999;46: 2100-2104. Pub Med

4) Aogi K, Hirai T, Mukaida H, et al. Laparoscopic resection of submucosal gastric tumors. Surg Today 1999;29:102-106. Pub Med

5) Choi YB, Oh ST. Laparoscopy in the management of gastric submucosal tumors. Surg Endosc 2000;14:741-745. Pub Med

6) Shimizu S, Noshiro H, Nagai E, et al. Laparoscopic wedge resection of gastric submucosal tumors. Dig Surg 2002;19:169-173. Pub Med

7) Reyes CD, Weber KJ, Gagner M, Divino CM. Laparoscopic vs open gastrectomy. A retrospective review. Surg Endosc 2001;15: 928-931. 1999;13:109-112. Pub Med

8) Kitano S, Shiraishi N, Fujii K, et al. A randomized controlled trial comparing open vs laparoscopy-assisted distal gastrectomy for the treatment of early gastric cancer: an interim report. Surgery 2002;131:S306-S311. Pub Med

9) Shimizu S, Uchiyama A, Mizumoto K, et al. Laparoscopically assisted distal gastrectomy for early gastric cancer: is it superior to open surgery? Surg Endosc 2000;14:27-31. Pub Med

10) Tanimura S, Higashino M, Fukunaga Y, Osugi H. Hand-assisted laparoscopic distal gastrectomy with regional lymph node dissection for gastric cancer. Surg Laparosc Endosc Percutan Tech 2001;11:155-160. Pub Med

11) Ballesta-Lopez C, Bastida-Vila X, Catarci M, et al. Laparoscopic Billroth II distal subtotal gastrectomy with gastric stump suspension for gastric malignancies. Am J Surg 1996; 171:289-292. Pub Med

12) Huscher CG, Anastasi A, Crafa F, et al. Laparoscopic gastric resections. Semin Laparosc Surg 2000;7:26-54. Pub Med

13) Adachi Y, Kitano S, Sugimachi K. Surgery for gastric cancer: 10-year experience worldwide. Gastric Cancer 2001;4:166- 174. Pub Med

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