Laparoscopic Radical Gastrectomy for Remnant Gastric Cancer

Summary

Laparoscopic radical gastrectomy for remnant gastric cancer has been increasingly adopted as a minimally invasive surgical approach in recent years. This article proposes a detailed operating procedure, aiming to provide practical technical guidance for surgeons and promote the broader adoption of laparoscopic surgery in managing remnant gastric cancer.

Abstract

Remnant gastric cancer (RGC) is a serious long-term complication following gastrectomy, for which radical resection remains the standard treatment. With continued advancements in laparoscopic techniques, laparoscopic radical gastrectomy (LRG) has emerged as an important therapeutic option for early-stage and select advanced cases of RGC. This procedure offers reduced surgical trauma, faster postoperative recovery, and a lower incidence of complications. However, several challenges remain in its clinical application. On the one hand, postoperative anatomical changes and intra-abdominal adhesions can limit the surgical field, complicating lymphadenectomy and digestive tract reconstruction. On the other hand, no consensus has been reached regarding the optimal surgical approach, the extent of lymphadenectomy, or the anastomotic technique, resulting in variation in procedural standardization. Nonetheless, with ongoing refinement of laparoscopic techniques, this approach has been increasingly adopted across multiple centers. Its successful implementation largely depends on the surgeons' technical proficiency and clinical experience. This study aims to systematically introduce the experiences of LRG for RGC and provide supplementary information for the existing research data on these techniques.

Introduction

Remnant gastric cancer (RGC) refers to a primary malignancy developing in the residual stomach after partial gastrectomy, which typically manifests more than five years after surgery. Although RGC has a relatively low incidence (about 2.6%)¹, it is frequently diagnosed at an advanced stage due to its long latency and nonspecific clinical presentation, leading to a poor prognosis². The pathogenesis of RGC is linked to multiple factors, including impaired mucosal defense, bile reflux, chronic inflammation, reconstruction technique, and Helicobacter pylori infection^3,4,5.

Similar to common gastric cancer, the treatment plan for residual gastric cancer mainly depends on the TNM staging. R0 resection is the preferred treatment option, and for patients who can undergo R0 resection, their prognosis is also similar to that of common gastric cancer.

Similar to common gastric cancer, the treatment for RGC mainly depends on the TNM stage. R0 resection is the preferred option, and for patients who can undergo R0 resection, the prognosis is similar to that of common gastric cancer^6,7,8. Although systemic chemotherapy, targeted therapy, and immunotherapy have shown progress in recent years, radical surgery remains the cornerstone of RGC treatment⁹. Conventional open surgery is often not preferred in elderly or high-risk patients due to extensive surgical trauma, high bleeding risk, and a high incidence of postoperative complications. Laparoscopy-assisted surgery for RGC was first reported by Yamada et al. in 2005¹⁰. Since then, with the growing adoption of minimally invasive techniques in gastric surgery, reports on laparoscopic radical gastrectomy (LRG) for RGC have gradually emerged. LRG offers advantages such as minimal trauma, faster recovery, and lower complication rates, making it a promising and increasingly utilized approach for RGC. Multiple studies have confirmed that, in experienced centers, LRG achieves R0 resection rates and lymph node yields comparable to those of open surgery, while significantly reducing intraoperative blood loss, shortening hospital stays, and facilitating faster gastrointestinal recovery^11,12,13.

However, LRG requires excellent anatomical orientation and advanced laparoscopic skills, particularly when dealing with adhesions near the anastomosis, jejunal mesentery, and splenic hilum, where procedural risks are high¹⁴. This article aims to systematically summarize the essential operative techniques and strategies in this procedure.

Protocol

The protocol was approved by the Institutional Review Board of The First Affiliated Hospital of Jinan University. This study included five patients who underwent LRG for RGC from January 2013 to December 2021.. Written informed consents were obtained from all the patients. The materials and the equipment used are listed in the Table of Materials.

1. Inclusion criteria

1. Include patients with a history of distal gastrectomy for benign or malignant conditions and a diagnosis of RGC more than 5 years after the initial surgery.
2. Confirm that pathological or imaging studies show the tumor is confined to the remnant stomach with no evidence of distant metastasis, and ensure preoperative evaluation confirms operability.
3. Verify through upper gastroenterography, enhanced CT scan, or endoscopy that there is no significant anastomotic stricture or esophageal invasion, indicating the tumor is resectable.

2. Exclusion criteria

1. Exclude patients with unresectable conditions, including peritoneal or liver metastases, or multiple fixed lymph node conglomerates.
2. Exclude patients with severe adhesions from previous upper abdominal surgeries that preclude safe laparoscopic access.
3. Exclude patients with clinically significant cardiac, pulmonary, or renal dysfunction.
4. Exclude patients who cannot tolerate general anesthesia or pneumoperitoneum.

3. Preoperative preparation

1. Perform routine laboratory tests, including complete blood count, urinalysis, stool examination, liver and renal function tests, coagulation function test, and tumor marker analysis.
2. Perform electrocardiography, chest CT, contrast-enhanced abdominal CT (Figure 1A,B), and upper gastrointestinal contrast (Figure 1C) before surgery.
3. Perform endoscopic biopsy to confirm the pathological diagnosis and assess anastomotic patency and tumor extent (Figure 1D).

4. Surgical technique

1. Anesthesia and positioning
   1. Administer general anesthesia via endotracheal intubation (following institutionally approved protocols). Place the patient in a supine position with legs spread at 45°-60°. Disinfect the surgical site using povidone-iodine.
   2. Stand between the patient's legs, with the assistant on the left and the laparoscope holder on the right. Adjust the surgical position intraoperatively as needed. When dissecting areas adjacent to the lateral abdomen, especially if instrument interference occurs with the laparoscope, stand on either side of the patient while the laparoscope holder moves between the patient's legs.
2. Pneumoperitoneum establishment and port placement
   1. Make a 10 mm vertical infraumbilical incision for Veress needle insertion and establish pneumoperitoneum by CO₂ insufflation to a pressure of 12 mmHg.
   2. Insert a 10 mm trocar at the umbilical site for laparoscope introduction. Under direct visualization, place two 12 mm trocars in the bilateral mid-abdomen and two 5 mm trocars in the bilateral upper abdomen.
3. Intraoperative exploration and adhesiolysis
   1. Conduct a thorough assessment of adhesions within the abdominal cavity and evaluate the presence of tumor implantation and infiltration of adjacent organs (Figure 2A-D). To avoid injury to the jejunal limb, pancreatic tail, mesocolon, and portal vein trunk, perform adhesiolysis using a combination of blunt and sharp dissection (Figure 2E,F).
      NOTE: Pay attention to areas prone to adhesions, such as the left hepatic lobe and remnant stomach, the transverse colon and greater omentum, and the splenic hilum and pancreatic tail.
4. Lymphadenectomy and organ mobilization
   1. Tailor lymphadenectomy for RGC according to the prior surgical approach, tumor location, and initial reconstruction method (Billroth I/II/Roux-en-Y). Follow the standard D2+ radical surgery guidelines, with special attention to ectopic nodes around the celiac axis, splenic hilum, and jejunal mesentery (Figure 3A-F, Figure 4A-F).
      NOTE: During lymph node dissection, maintain awareness of altered lymphatic drainage pathways resulting from previous gastric surgery. Pay particular attention to ectopic lymph nodes located along the mesenteric border and adjacent to the colic arteries to avoid missed metastases.
   2. Mobilize the cardia and at least 6 cm of the distal esophagus using an ultrasonic scalpel (Figure 5A) to ensure a safe and tension-free anastomosis, especially for tumors involving the cardia or distal esophagus.
      NOTE: If the lesion involves the pancreatic tail or splenic hilum, perform a combined distal pancreatectomy or splenectomy as indicated.
5. Remnant stomach resection and digestive tract reconstruction (Roux-en-Y anastomosis)
   1. For cases with previous distal gastrectomy and Billroth II reconstruction, transect the jejunal input and output loops at the prior gastrojejunostomy using a linear stapler (Figure 5B,C).
      NOTE: If the tumor involves the previous gastrojejunostomy, remove the jejunal input and output loops approximately 10 cm away from the anastomosis.
   2. When the tumor does not involve the cardia, perform a side-to-side esophagojejunostomy using a linear stapler before transecting the lower esophagus to prevent retraction into the thoracic cavity after transection (Figure 5D-F).
      NOTE: When the tumor involves the cardia, first transect the lower esophagus using a linear stapler to preserve tumor integrity, then perform side-to-side esophagojejunostomy.
   3. Perform a side-to-side jejunojejunostomy at the distal jejunum located 45 cm from the esophagoduodenal anastomosis (Figure 6A,B).
      NOTE: Ensure all anastomoses are tension-free and patent to prevent leakage and stenosis. Inject the methylene blue solution through the gastric tube after completion of all anastomoses. Absence of dye leakage confirms anastomotic integrity.
6. Specimen extraction and incision suturing
   1. Place the resected specimen in a sterile retrieval bag. Irrigate the surgical field with sterile distilled water to ensure hemostasis and confirm the absence of gastric leakage (Figure 6C).
   2. Place one or two drainage tubes near the left subphrenic space and around the jejunal anastomosis to facilitate postoperative monitoring and prevent complications such as anastomotic leakage (Figure 6C).
   3. Extend the umbilical incision to approximately 6-8 cm to remove the specimen bag. Send the sample for intraoperative rapid frozen pathological examination and postoperative routine pathological analysis (Figure 6D). After confirming negative margins via frozen section, remove all trocars and close the abdominal incisions to complete the procedure.

5. Postoperative procedure

1. Continuously monitor vital signs, including heart rate, blood pressure, respiratory rate, and temperature, to enable early detection and management of postoperative complications.
2. Administer intravenous antibiotics, somatostatin analogs, and hepatoprotective agents, and adjust regimens based on individual patient conditions. For patients without infectious complications, ensure that prophylactic antibiotic use after surgery does not exceed 48 h.
3. Inspect surgical incisions regularly for signs of infection, such as erythema or exudate, and provide prompt intervention when infection is suspected.
4. In the absence of anastomotic leakage, remove abdominal drains 5-7 days after surgery.
5. Perform routine blood tests regularly, including complete blood count and other relevant parameters.

Results

A total of 5 patients (median age: 73 years, range: 57-77 years), all of whom were male, underwent laparoscopic radical gastrectomy for remnant gastric cancer. The original disease in all cases was benign, and all patients had previously undergone open distal gastrectomy with Billroth-II reconstruction. The median interval between the initial surgery and the diagnosis of remnant gastric cancer was 480 months (range: 300-696 months). The median body mass index (BMI) of the patients was 22.1 kg/m² (range: 20.1-2...

Discussion

RGC is a primary malignancy that arises in the residual stomach after partial gastrectomy. It was first described by Balfour in 1922¹⁵. Although the overall incidence of RGC remains relatively low, it has been steadily rising due to improvements in gastric cancer detection and increased postoperative survival¹⁶. A previous gastrectomy often results in extensive intra-abdominal adhesions and altered anatomy around the remnant stomach, particularly in lymphatic drainage pathw...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
10-mm trocar	Xiamen Surgaid Medical Device Co., LTD	NGCS 100-1-10	Sterile, ethylene oxide sterilized, disposable
12-mm trocar	Xiamen Surgaid Medical Device Co., LTD	NGCS 100-1-12	Sterile, ethylene oxide sterilized, disposable
5-mm trocar	Xiamen Surgaid Medical Device Co., LTD	NGCS 100-1-5	Sterile, ethylene oxide sterilized, disposable
Hem-o-lok	America Teleflex Medical Technology Co., LTD	544240	Sterile, ethylene oxide sterilized, disposable
Linear stapling device	America Ethicon Medical Technology Co., LTD	PSEE60A	Sterile, ethylene oxide sterilized, disposable
Pneumoperitoneum needle	Xiamen Surgaid Medical Device Co., LTD	NGCS 100-1	Sterile, ethylene oxide sterilized, disposable
Suction and irrigation tube	Tonglu Hengfeng Medical Device Co., LTD	HF6518.035	Sterile,dry heat sterilized, reusable
Ultrasounic-harmonic scalpel	Chongqing Maikewei Medical Technology Co., LTD	QUHS36S	Sterile, ethylene oxide sterilized, disposable