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J. St. Marianna Univ.
Vol. 6, pp. 273–278, 2015
Original Article
Short-term Outcomes of Laparoscopic Surgery for Synchronous Gastric
and Colorectal Cancer
Ryoji Makizumi1, Shinya Mikami1, Kuniyasu Horikoshi2, Tsukasa Shimamura3,
Shinjiro Kobayashi1, Akira Hanai1, Satoshi Tsukikawa1, Yukihito Kokuba2,
Nobuyoshi Miyajima4, and Takehito Otsubo1
(Received for Publication: September 25, 2015)
Abstract
Background Although laparoscopic gastrectomy and laparoscopic colorectal surgery are being performed at in‐
creasing regularity, simultaneous laparoscopic surgery for synchronous gastric and colorectal cancer is rare, and
its feasibility and safety are unknown. We addressed this question by retrospectively evaluating the short-term
surgical outcomes of simultaneous laparoscopic surgery performed at our hospital for synchronous gastric and
colorectal cancers.
Methods The study group comprised 8 patients (5 men, 3 women, aged 51–84 years) who underwent simultane‐
ous laparoscopic gastrectomy and colorectal surgery at St. Marianna University School of Medicine Hospital
between 2011 and 2014. Patients were followed up for at least 14 months. We reviewed patient and tumor char‐
acteristics; comorbidities; specific surgical procedures performed; short-term surgical outcomes, including oper‐
ation time, estimated intraoperative blood loss; postoperative morbidity; duration of postoperative hospital stay;
recurrence or metastasis; and mortality.
Results Median operation time for the simultaneous surgery was 674 min, and median estimated blood loss was
242 mg. There were no intraoperative complications, and no conversion to open surgery was necessary. Postop‐
erative morbidity occurred in 2 patients—ileus in 1 and pulmonary edema in 1. Median postoperative hospital
stay was 15.5 days. There were no postoperative deaths.
Conclusion Short-term outcomes in our patient group suggest that simultaneous laparoscopic surgery is both
feasible and safe for patients with synchronous gastric and colorectal cancer.
Key words
laparoscopy, synchronous gastric and colorectal cancer
6.8%2–6). Because surgical resection with lymphade‐
nectomy is the standard treatment for both gastric and
colorectal cancer, simultaneous resection is indicated
if a curative result is expected for both cancers when
they are synchronous. Laparoscopic surgery has
shown to be both feasible and safe for treating pa‐
tients with synchronous gastric and colorectal can‐
cer7–9). Currently, laparoscopic colectomy (LAC) is
Introduction
Colorectal cancer is the third most common can‐
cer in men and second most common cancer in
women worldwide, and gastric cancer is the fourth
most common cancer in both men and women world‐
wide1). Synchronous colorectal cancer in patients
with gastric cancer has a reported prevalence of 1.3–
1
2
3
4
Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine
Department of Gastroenterological and General Surgery, St. Marianna University Yokohama City Seibu Hospital
Department of Gastroenterological and General Surgery, Kawasaki Municipal Tama Hospital
Digestive Disease Center, St. Marianna University School of Medicine Toyoko Hospital
171
Makizumi R Mikami S et al
274
Surgical procedures
The procedures were performed by surgeons
with experience in 50 or more laparoscopic surgeries.
Patients, under general anesthesia, were placed in the
supine position with legs apart. For all patients, LAG
was performed first, then LAC. Two 12-mm ports
were inserted, 1 on either side of the upper abdomen,
2 5-mm ports were inserted, 1 on either side of the
middle abdomen at the level of the umbilicus, and a
camera trocar was inserted at the umbilicus. An addi‐
tional 12-mm port was placed in the right lower ab‐
domen during LAC. Intraabdominal pressure was
maintained at 8–10 mmHg. In cases of LADG or py‐
lorus-preserving gastrectomy, enteric anastomosis
was achieved extracorporeally. A mini-laparotomy
incision was made by extending the umbilical wound
4–5 cm at the midline in all patients. The resected
stomach was extracted through this mini-laparotomy.
For cases of laparoscopic total gastrectomy, esopha‐
gojejunostomy was performed intracorporeally. Col‐
orectal anastomosis was performed intracorporeally
by means of a double stapling technique. All resected
tumors were examined pathologically. Pathological
staging was based on the Union for International
Cancer Control TNM Classification of Malignant Tu‐
mours, 7th edition11).
performed worldwide as a standard treatment, and the
short-term clinical benefits of LAC in comparison to
conventional open surgery have been reported7–8).
Furthermore, laparoscopy-assisted distal gastrectomy
(LADG), in comparison to open distal gastrectomy,
has been reported to reduce blood loss, decrease the
frequency of analgesic administration, lead to faster
recovery and a shorter hospital stay, and result in
fewer postoperative complications10). We conducted a
retrospective study to evaluate the technical feasibil‐
ity and safety of laparoscopic surgery for synchro‐
nous gastric and colorectal cancers in 8 consecutive
patients.
Patients and methods
Between January 2011 and December 2014, 955
patients underwent surgical resection with lymphade‐
nectomy for gastric cancer (n=416) and/or colorectal
cancer (n=539) at St. Marianna University School of
Medicine Hospital. Nine of these 955 patients had
synchronous gastric and colorectal cancer, and 8 of
the 9 underwent simultaneous laparoscopy-assisted
gastrectomy (LAG) and LAC. Surgical records of
these 8 patients were made available for our review,
as were the postoperative pathology reports. Patho‐
logical staging was based on the Union for Interna‐
tional Cancer Control TNM Classification of Malig‐
nant Tumours, 7th edition11). All patients were fully
informed of the details of the operative procedure,
and all patients provided informed consent for it. We
obtained approval of the St. Marianna University
School of Medicine Ethics Committee (approval
number: 3163).
Variables evaluated
In evaluating the feasibility and safety of simul‐
taneous laparoscopic surgery for synchronous gastric
and colorectal tumors, we investigated patient and tu‐
mor characteristics; comorbidities; specific surgical
procedures performed; short-term surgical outcomes,
including operation time, estimated intraoperative
blood loss, postoperative morbidity, and duration of
postoperative hospital stay; recurrence or metastasis,
and mortality.
Indications for LAG and LAC
LAG and LAC were performed according to in‐
dications accepted at our hospital. LAG is performed
for cT1–3N0–1 gastric cancer. Generally, LADG
with D1+ lymph node dissection was performed for
cT1N0 gastric cancer, i.e., early-stage gastric cancer,
LADG with D2 lymph node dissection was per‐
formed for cT2–3 gastric cancer without obvious
lymph node swelling. The extent of dissection was
determined according to the Japanese Guidelines for
the Treatment of Gastric Cancer12). LAC was per‐
formed for colorectal cancer without clinically evi‐
dent invasion of the adjacent organs. All patients un‐
derwent preoperative evaluation, and the decision to
perform simultaneous laparoscopic surgery was made
when the criteria for each operative procedure were
met.
Results
Clinical characteristics of the 8 patients who un‐
derwent laparoscopic surgery for synchronous gastric
and colorectal cancer are shown on Table 1. The
male/female sex ratio was 5/3, and median age was
76 years (range, 51–84 years). Patient 1 had multiple
gastric cancers, including low rectal cancer, so lapa‐
roscopic total gastrectomy and laparoscopic abdomi‐
noperineal resection with D3 dissection were per‐
formed simultaneously; a sigmoid colostomy was
made. Patients’ short-term surgical outcomes and
pathology findings are shown in Table 2. Median op‐
eration time was 674 minutes, and median estimated
172
Laparoscopic Surgery for Synchronous GI Cancer
275
Table 1. Study Patients, Tumor Characteristics, and Comorbidities
Table 2. Surgical Outcomes and Pathology Findings
blood loss was 242 mg. There were no intraoperative
complications, and no patient required conversion to
open surgery. All laparoscopic procedures were per‐
formed as planned, with no intraoperative adjust‐
ments. Postoperative morbidity occurred in 2 patients
—ileus in 1 and pulmonary edema in 1. Median post‐
operative hospital stay was 15.5 days. The median
number of lymph nodes retrieved was 36.5 in associ‐
ation with gastric lesions and 18 in association with
colorectal lesions. Six of the 8 patients were followed
up at our hospital for at least 14 months, with 1 of the
6 followed up for 43 months, and there was no evi‐
dence of cancer recurrence or metastasis in any of
these 6 patients.
Discussion
Laparoscopic surgery is currently performed
worldwide. The number of laparoscopic surgeries, in‐
cluding LAG and LAC, performed in Japan has
steadily increased with technological advances in op‐
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276
Makizumi R Mikami S et al
tical and surgical devices. LAC is now recommended
as a standard treatment for colorectal cancer because
it results in minimal damage to the abdominal wall
and a quick recovery without sacrificing the oncolog‐
ical outcome13)14). Fukunaga et al. reported good on‐
cologic outcomes for patients with gastric cancer
treated by LADG with extended lymph node dissec‐
tion15). The conventional treatment of synchronous
gastric and colorectal cancer has been open surgery.
This surgery requires a long medial incision from the
xiphoid to the pubis for simultaneous gastrectomy
and colorectal resection.
Simultaneous laparoscopic surgery for synchro‐
nous gastric cancer and colorectal cancer is theoreti‐
cally feasible 15–23). Such surgery for gastric and color‐
ectal cancer has many advantages, including good
cosmetic results, reduced postoperative pain, and a
reduced incidence of complications. However, the
technical difficulty of the simultaneous laparoscopic
resections is high, and there is a greater risk for addi‐
tional problems because it is seldom performed; the
need for it occurs only rarely2–6). Also, the operation
time for laparoscopic surgery is greater than that for
open surgery. In 39 reported cases of simultaneous
laparoscopic gastrectomy and colorectal resection,
the median operation time was 365 minutes (range,
165–746 minutes)16–24). The median operation time
for our 8 patients was 674 minutes (range, 332–903
minutes). For 1 patient, more than 900 minutes were
required to complete simultaneous laparoscopic total
gastrectomy with D2 dissection and abdominoperi‐
neal resection with D3 dissection. Although the oper‐
ation time in this case was considerably longer than
that in the other 7 cases, no surgical or postoperative
complications developed, and the patient was dis‐
charged 20 days after surgery. Thus, even when the
operation time was long, the outcome was good, like
that for other patients, so we consider simultaneous
laparoscopic gastrectomy and colorectal resection
beneficial for patients in whom the operative criteria
are met. Because both the surgical operator and the
assistant are exhausted by the long operation time, si‐
multaneous laparoscopic gastrectomy and colorectal
resection are performed by 2 different teams at our
hospital. Surgery performed by different teams re‐
duces the physiological and psychological stress ex‐
perienced by the operator and assistant.
Optimal port placement and mini-laparotomy
placement are additional challenges associated with
the simultaneous procedure. For left-sided rectosig‐
moid lesions, it may be difficult to perform simulta‐
neous resection via shared ports and a mini-laparot‐
omy incision. It may also be necessary to add some
ports for lymph node dissection during laparoscopic
colorectal surgery17). We inserted an additional 12mm port into the right lower abdomen during LAC.
The oncologic feasibility of laparoscopic sur‐
gery for malignant disease is still under investigation.
However, laparoscopic surgery has been shown to be
feasible and safe and to provide favorable short- and
mid-term outcomes for patients with stage I and II
rectal cancer7). In the present study, LAC with D3
lymph node dissection was performed for patients
with stage I, II, or IIIa colorectal cancer. LAG is gen‐
erally indicated for cT1–3N0–1 gastric cancer at our
hospital. LAG with D1+ lymph node dissection was
performed in 3 patients with cT1N0 early gastric can‐
cer, and LAG with D2 lymph node dissection was
performed in 4 patients with cT2–3 gastric cancer.
The median number of dissected lymph nodes in our
patient series was similar to that in other reported ser‐
ies8)13)15)18)20)24). There was no evidence of recurrence
or metastasis during the follow-up period in any of
our study patients.
Conclusion
We recognize the limitations of our study, in‐
cluding its retrospective nature and small patient
group. However, after evaluating the clinical charac‐
teristics, surgical procedures, and outcomes of 8 pa‐
tients who were successfully treated with simultane‐
ous laparoscopic surgery for synchronous gastric and
colorectal cancers, we conclude that this laparoscopic
approach is both feasible and safe when performed
by an experienced surgeon.
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