Introduction

In several Asian countries, including Japan and Korea, it has been reported that the frequency of synchronous gastric and colorectal cancer ranges between 0.8% and 3.9% [1–3]. Surgical resection with lymphadenectomy is the standard treatment for both gastric and colorectal cancer; thus, simultaneous resection is indicated if curative resection is expected for both cancers [4, 5]. If conventional open surgery is indicated, a wide laparotomy, from the xiphoid to the pubic symphysis, is occasionally required, which results in a poor cosmetic result and impaired postoperative quality of life.

Today, laparoscopy-assisted colorectal surgery (LAC) is performed worldwide as the standard treatment for colorectal cancer, and the advantages of this technique over conventional open colorectal surgery have been documented [6]. In Korea and Japan, where the incidence of early gastric cancer is high, the number of laparoscopy-assisted gastrectomies (LAG) performed for gastric cancer is increasing gradually [7]. The advantages of LAG over conventional open gastrectomy have also been documented [8–11]. In cases of synchronous gastric and colorectal cancer, theoretically both could be treated by laparoscopy. However, this type of surgery is rarely performed and is found in the literature usually as a case report only [12, 13].

In the present study, early surgical outcomes following simultaneous LAG and LAC were investigated in seven consecutive patients to clarify the feasibility of this type of surgery.

Materials and methods

Between April 2005 and October 2008, 638 patients underwent LAG with lymphadenectomy for gastric cancer at the Cancer Institute Hospital. Of these 638 patients, seven had synchronous colorectal cancer. All seven patients underwent simultaneous LAC and were thus included in the present study. Early surgical outcomes, including operation time, estimated intraoperative blood loss, postoperative morbidity, mortality, and the duration of the postoperative hospital stay, were determined from medical charts. Pathological data were also collected from pathological records. The pathological stage of tumors was determined according to the International Union Against Cancer (UICC) criteria [14].

Indication for LAG and LAC

In the present study, LAG was generally indicated for cT1 early gastric cancer with no evident lymph node metastasis (Stage IA). In patients with cT2a gastric cancer without obvious lymph node swelling, LAG with D2 lymph node dissection was performed; LAC was indicated in patients with colorectal cancer with no clinically evident invasion to the adjacent organs [15].

In patients with synchronous gastric and colorectal cancer that does not fulfill the criteria for LAG or LAC, simultaneous laparoscopic surgery was not indicated. Between April 2005 and October 2008, 15 patients were diagnosed as having synchronous gastric and colorectal cancer, both of which required surgical resection. Eight of whom had advanced gastric cancer; thus, simultaneous laparoscopic surgery was not indicated. The remaining seven patients fulfilled criteria for laparoscopic approach; thus underwent laparoscopic surgery and included in the present study.

Surgical procedure

Details of the LAG and LAC procedures have been described previously [15–20].

In cases of laparoscopy-assisted distal gastrectomy or pylorus-preserving gastrectomy, an enteric anastomosis is performed extracorporeally and, thus, an upper midline incision (5–6 cm) is required. Retrieval of the resected specimen and colorectal reconstruction are performed through the same incision (Fig. 1).

Fig. 1
figure 1

1 A minilaparotomy (5–6 cm) during simultaneous laparoscopy-assisted distal (pylorus-preserving) gastrectomy and laparoscopy-assisted colorectal surgery. Note that the position of the upper abdominal mini-incision is lower than usual position for the laparoscopy-assisted distal (pylorus-preserving) gastrectomy (dotted line). 2 A minilaparotomy during simultaneous laparoscopy-assisted total gastrectomy and laparoscopy-assisted right hemicolectomy. This small skin incision was made by extending the camera port around the navel. 3 A minilaparotomy during simultaneous laparoscopy-assisted total gastrectomy and sigmoidectomy or anterior resection

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In cases of laparoscopy-assisted total gastrectomy, an esophagojejunostomy is performed intracorporeally; thus, the position of the minilaparotomy is dependent on the LAC procedure (Fig. 1).

Results

Table 1 lists the characteristics of the seven patients who underwent simultaneous laparoscopic surgery. In one patient (No. 2) who had multiple colon cancers, right colectomy and sigmoidectomy were performed simultaneously in addition to distal gastrectomy. The site for the minilaparotomy was the midline in six patients and the left side of the abdomen in one patient who underwent simultaneous laparoscopy-assisted total gastrectomy and anterior resection.

Table 1 Characteristics of patients who underwent simultaneous laparoscopic surgery
Full size table

Surgical and pathological findings are also shown in Table 1. Mean operation time was 392 min and estimated blood loss was 90 mg in patients undergoing simultaneous laparoscopic surgery. There were no intraoperative complications and no conversion to open surgery was required in any patient. Postoperative morbidity was found in three patients, including surgical site infection, enteritis, and gastric fullness. The former two patients recovered well and were discharged on the 15th and 19th postoperative day, respectively. Although the patient who complained of gastric fullness required a longer hospital stay as compared with the other six patients because of insufficient oral intake, he was discharged on the 51st postoperative day after recovery of nutritional status.

Discussion

The number of laparoscopic surgeries, including LAG and LAC, performed in Japan is increasing [7], although descriptions of simultaneous LAG and LAC are mainly case reports [12, 13]. Simultaneous laparoscopic surgery for both gastric and colorectal cancer may have many advantages, such as a good cosmetic result and improved postoperative quality of life. In addition, the small skin incision required in laparoscopic surgery is associated with less postoperative pain and early mobility, which may result in a decrease in the incidence of pulmonary embolization [21]. Moreover, this small skin incision and laparoscopic procedures contributed to less manipulation of the small intestine compared with that in conventional open surgery, which resulted in decreased expression of inflammatory cytokines and decreased incidence of postoperative bowel obstruction due to adhesion [18, 22]. However, compared with conventional open surgery, LAG and LAC are time-consuming procedures. Therefore, conventional open surgery is generally indicated in simultaneous gastric and colorectal cancer.

In the present study, two patients underwent laparoscopy-assisted total gastrectomy, whereas the remaining five patients underwent laparoscopy-assisted distal or pylorus-preserving gastrectomy for gastric cancer. In cases of laparoscopy-assisted distal or pylorus-preserving gastrectomy, we changed the position of the upper abdominal mini-incision to one that was lower than usual for LAG as well as right side or left side colon were mobilized to a greater extent than is usual to make it easier to make the anastomosis through the minilaparotomy. Actually, we did not experience any trouble associated with enteric anastomosis in this study.

Although many advantages of laparoscopic surgery have been reported before, laparoscopic approach also has some limitations. First, it generally requires longer operation times compared with conventional surgery. In the present study, mean operation time was relatively longer (392 min); one patient needed more than 9 h to finish simultaneous laparoscopic surgery. Although future technical advances may shorten the time required for laparoscopy, surgeons should not hesitate to convert to conventional open surgery if operation takes too long or intraoperative complication such as massive bleeding or enteric injury occurs. Second, the oncologic feasibility of laparoscopic surgery for malignant disease, particularly for gastric cancer, is still under investigation. Thus, in the present study, we restricted the application of LAG to the patients with stage IA or some selected stage IB gastric cancer.

A large-scale study investigating simultaneous laparoscopic surgery is difficult because the incidence of cases of simultaneous gastric and colorectal cancer in which both meet the indications for laparoscopic surgery is not very high; thus, most previous documentations of this sort of surgery are case reports [12, 13]. In comparison, the present study evaluated seven patients who were treated successfully by simultaneous laparoscopic surgery. We believe that simultaneous laparoscopic surgery is feasible and should be indicated, provided it is performed by an experienced surgeon