Laparoscopy-assisted distal gastrectomy (LADG) has been used to treat early gastric cancers not requiring extensive lymph node dissection.
The advantages of this procedure, when compared with the conventional open method, include less operative blood loss, less pain, earlier recovery of bowel activity, earlier resumption of oral intake, and a shorter hospital stay.
LADG can result in an adequate gastrectomy and achievement of appropriate lymph node dissection. However, operative time is longer, and the procedures are considered to be technically complicated when compared with the open method.
There is a high morbidity rate during and after surgery in obese patients. Although it is thought that the quick recovery after laparoscopic surgery would benefit obese patients, few data exist supporting this conclusion. There have been few studies investigating the feasibility and safety of laparoscopic surgery for cancer in obese patients.
The authors defined a body mass index >/=24.2 as the high-BMI group, which is smaller compared with the western criteria of obesity. The high-BMI group in the present study should be defined as heavier weight rather than obesity.
They experienced difficulty performing LADG in patients in the high-BMI group because of insufficient visualization of the abdominal cavity by the well-developed omentum. Pneumoperitoneum in the upper abdomen of male patients of heavier weight is
limited, compared with that in the pelvic cavity of multiparous female patients.
To reduce the incidence of extension of the incision for the reconstruction, a new device for
laparoscopic surgery needs to be evolved.
Recovery of bowel activity in the high-BMI group was significantly delayed compared with the time in the normal-BMI group. They observed a significant correlation between operative
time and time to first flatus in this study. They speculate that operative stress on the intestine, which could not be estimated in the present study, may have been more intense in patients of heavier weight due to longer surgical time. However, direct manipulation of the intestine was minimal during LADG. They suggest that the Roux-en-Y reconstruction may also have affected the
time to first flatus. Despite the disadvantage of the delayed recovery of bowel activity in the short-term period after surgery in patients of heavier weight, Hirokazu Noshiro et al. have not observed any patients suffering from ileus or incisional hernia after LADG.
The authors could not estimate pain control after surgery because of the standardized postoperative care using continuous epidural injection of local anesthetics in their department.However, this kind of postoperative pain control shortened the time to first flatus (mean 2.6 days in patients with normal BMI) when compared with another report.
The length of hospital stay could not be estimated correctly because of health care practices in Japan. In contrast to the new emphasis on early patient discharge in western countries, the length of hospital stay in Japan is still determined by agreement between the patient and the attending
physician.
A randomized control study with a longer follow-up period is needed to assess whether lapa-roscopic surgery is superior to laparotomy for treating obese patients with early gastric cancer. This retrospective study is preliminary but informative, suggesting that LADG in patients of heavier weight is accompanied by more surgical difficulties compared with patients with a normal BMI.
There are still benefits of a decreased incidence of serious wound and hernia complications in successful cases
( 1 ).
References
1) Hirokazu Noshiro, Shuji Shimizu, Eishi Nagai, Kenoki Ohuchida, and Masao Tanaka. Laparoscopy-Assisted Distal Gastrectomy for Early Gastric Cancer. Is It Beneficial for Patients of Heavier Weight? Ann Surg 2003;238: 680-685. Pub Med
