LAG is less invasive than conventional open gastrectomy. It leads to a faster recovery of gastrointestinal functions and a reduction of pain and, furthermore, there is no significant differences in complication and mortality rate between the two. Recently, randomized controlled trial by Huscher et al (Huscher et al, 2005) and prospective multi-center trial by Kitano et al (Kitano et al, 2007) showed that EGC patients who underwent LAG showed five-year survival rates, indicating excellent oncologic outcomes. Together with the development of operation skills and operation devices, LAG is being used in expanded indication, including more expanded lymph node dissection (D1+ or D2), total gastrectomy, and advanced cancer. However, there are not enough studies on the factors that increase complications when such complicated procedure is performed.
Several studies which examined complication and mortality rates related to LAG, LAG shows similar or better results when compared with conventional open gastrectomy. Huscher et al (Huscher et al, 2005) in their randomized controlled study observed that mortality and morbidity rates related to LAG were 3.3 % and 26.7 %, respectively, showing no significant difference from those of open gastrectomy 6.7 % and 27.6 %, respectively; Kitano et al (Kitano et al, 2007) in their Japanese multi-center trial on 1294 patients of early gastric cancer found that mortality and morbidity rates were 0 % and 14.8 %, respectively. However, in the study of Kitano et al, patients with cancer in other organs, advanced cancer, previous upper abdominal laparotomy or organ insufficiency were not included; In the study on 140 gastric cancer patients, Kim et al (Kim et al, 2007) found that overall mortality and
morbidity rates were 0.7 % and 18.6 %, respectively; In the meta-analysis into LADG and conventional open distal gastrectomy, Hosono et al (Hosono et al, 2006) showed that LADG excelled in terms of complication and there were no significant differences in anastomosis, pulmonary, wound complication, and mortality.
This study constitutes a short-term outcome for gastric cancer patients who underwent LAG by a single operator at a single center, and aimed to elucidate the complication-related risk factors via univariate and multivariate analyses, and to emphasize the need for a learnig curve to guarantee safety which is acceptable for performing complicated procedures such as LAG, or selecting proper patients for LAG.
In this study, 61 (20.3 %) out of 300 patients developed complications after operation and, among these patients, 18 (36 %) out of 50 patients developed complications during the 1st period, before completing the learning curve, and 43(17.2 %) out of 250 patients developed complications during the 2nd period, after completion of the learning curve. In the univariate analysis into risk factors that lead to development of complications, male patients, patients with comorbidity, longer operative time, and 1st period had increasing possibilities of developing complications. When multivariate analysis was made based on the univariate analysis, we found a meaningful increase in the development of complications in cases with comorbidity and in the 1st period.
Generally speaking, all patients for whom it is possible to administer general anesthesia can be considered for laparotomy and laparoscopic operation. However, we need to be cautious in choosing laparotomy or laparoscopic operation, because pneumoperitoneum may influence pulmonary capacity or cardiac reserve in patients with severe pulmonary or cardiac
disease. We also found that the development of complications significantly increased in patients with comorbidity. Furthermore, there were cases in which patients with senility and many comorbidities had to stay in the hospital longer than expected, because they showed delayed recovery of general conditions, even without the development of particular complications.
There have been several studies on the effect of comorbidity on operative risk: Zingmond et al (Zingmond et al, 2003) stated that after operations on colorectal cancer patients, patient characteristics, such as age, comorbidiy, and acuity of surgery are important factors for serious medical and surgical complications; Jamal et al (Jamal et al, 2005) observed in their study on gastric bypass of 1465 morbid obesity patients, that there was a much greater number of early postoperative complications in patients with major comorbidity than with those who had minor comorbidity or patients without comorbidity, and that the difference was more than 10 times in mortality; Matin et al (Matin et al, 2003) reported that, in cases of laparoscopic renal and adrenal surgery patients by multivariate analysis, the lower the comorbidiy index, the less the patients experience postoperative complications. The study also showed that those who were older than 65 years could be a factor in delaying the morbidity, and mortality as important parameters. Eto et al (Eto et al,2006), in their study on
laparoscopic adrenalectomy, reported that open conversion and transfusion were not needed after operation of 42 cases; Kanno et al (Kanno et al, 2006), in their research on laparoscopic nephrectomy, stated that the more experience a surgeon has, the less complication rate and operation time grew, and the numbers revealed a notable decrease after 50 cases; Vaisbuch et al (Vaisbuch et al, 2006), in their comparative study on laparoscopic hysterectomy and total abdominal hysterectomy, observed that the more experience a surgeon has, the bigger the decrease in the operation time, complication rate and length of hospital stay; Reissman et al (Reissman et al, 1996), in their study on laparoscopic colorectal surgery of 100 cases, stated that learning curve and types of procedures affected the morbidity; Kim et al (Kim et al, 2005), in their study on learning curve of LADG, observed a result similar to the present study, showing a notable improvement in operating time after operation of 50 cases.
What was notable in this study is the fact that a considerable decrease was found in terms of operative time and development of complication until 50 cases, but there was a slight increase after 50 cases, followed by an another decrease, then reaching a plateau (Fig. 2).
This is most likely due to the extension of patient selection, such as patients with many comorbidities, advanced case and total gastrectomy, and also the extension of lymph node dissection such as D1+β or D2 dissection after the learning curve.