[Criteria for training in laparoscopic gastric surgery: guidelines and experience of 30 cases]

Although many studies on laparoscopic surgery of the stomach have been conducted so far, yet they have not provided surgeons with criteria for gradual and safe training with this technique. The results of gastric surgery with 30 patients operated on by laparoscopic approach are hereby described. The aim of this issue is to provide surgeons with guide lines for progressive training, respectful to patients, complying with oncologic criteria and useful to reduce conversion rate or drawbacks at the start of the experience.

The Authors made a retrospective analysis on 30 patients affected by gastric lesions, 5 benign chronic ulcers and 25 neoplasms of the stomach. Our guide lines suggest that the training begin with the treatment of benign lesions, followed by early gastric cancer (EGC) and by advanced gastric cancer (AGC) of the antrum. Our experience started with 4 laparoscopic subtotal distal gastrectomies (LSGs) for benign ulcer; independent of the guidelines hereby proposed 1 laparoscopic total gastrectomy (LTG) was done after the intraoperative finding of a benign ulcer of the lesser curve penetrating into the left hepatic lobe. The beginning of training included also 1 LSG for distal stromal tumor (GIST). Subsequently 13 early gastric cancers (EGC) were operated on: echoendoscopy could demonstrate 12 T1 m and 1 T1 sm and no evidence of nodal involvement. The diameter of EGCs was 1,3 cm on average ( range 0,7-4 cm), all were marked by Indian ink to allow performance of 10 LSGs and 3 LTGs. Moreover, 8 LSGs for advanced gastric carcinoma (AGC) of the antrum were carried out. The training in malignancies progressed with LTG for 2 non-Hodgkin gastric lymphomas; 1 lymphoma required conversion to laparotomy due to infiltration of the diaphragmatic crus. A D2 lymphadenectomy was associated to gastrectomy in adenocarcinomas.

The feasibility of laparoscopic gastric surgery was confirmed by this study, with operating time of 240 minutes (range 150-360), intraoperative blood loss was 180 ml (range 100-250), and only 1 patient required blood transfusion for postoperative bleeding. The specific morbidity rate was 10% owing to duodenal leakage in 3 cases in the early phase of this study (3/30): 1 required laparotomy. The mortality rate was 3% due to 1 serious postoperative bleeding and acute hepatic failure in a patient with post-alcoholic cirrhosis. The conversion rate was 3% (1/30). The nasogastric tube was removed on the 4(th) postoperative day, and the oral intake started on the 6(th) postoperative day after a barium follow-through examination. The mean postoperative hospital stay was 16 days (range 10-25). The number of nodes retrieved was 18 on average and it improved with the experience: from the minimum of 9 nodes in benign ulcers, it grew to 20 in EGCs and to 25 in AGCs, so that this data confirmed the guide lines proposed in this issue . The histologic examination of EGC confirmed the data of echoendoscopy about nodal status.

Laparoscopic surgery is a safe and feasible procedure both for benign and for malignant lesions of the stomach. The results analysed hereby suggest that at the start of training be treated patients affected by benign lesions, followed by patients with EGC and then by patients with AGC. For gastric cancers, the average number of 18 nodes harvested from each patient was adequate, complying with the requirements suggested by the latest TNM classification. This choice of progressive selection of patients for training represents a good means to get an optimal performance level, especially in view of the oncologic requirements, and can prevent surgeons from elevated conversion rates and disappointing outcomes at the beginning of experience.