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1. Is There An ideal time for Gastric Cancer Surgery
Ahmed AlRomi
General Surgery Specialist
Fellow Of Upper GI And Bariatric & Metabolic Surgery
Korea University Anam Hospital (KUAN)
Ministry of Health
General Surgery Department
Ministry of Health of Jordan

2. Is There an Ideal Operative Time For Gastric Cancer Surgery
Ahmad ALRomi1.2, Shin-Hoo PARK2, Chang Min LEE3, Huang HUA4, Sungsoo Park2
1 Division of General Surgery, Jordanian Ministry of Health , Jordan
2 Division of Foregut Surgery, Korea University Anam Hospital, Korea
3 Division of Foregut Surgery, Korea University Ansan Hospital, Korea
4 Department of Gastric Cancer and Soft Tissue Sarcoma, Fudan University, China
Nothing to disclose

3. CLICK TO ADD TITLE
To date, the ideal operative time range has not been established, and there is widely
suggested hypothesis that a shorter operative time leads to better clinical outcomes
Several studies have reported the impact of operative time on clinical outcomes
although none of them have provided a specific guideline on the optimal operative
time range for LCS
Introduction

4. set to internally validate whether
the estimated ideal operative time
range was feasible by comparing
the operative outcomes of patients
with shorter, ideal, and longer
operative time ranges.
Patients and Study design
prospectively collected database
of 379 patients with laparoscopic
distal gastrectomy from 20
institutions in Korea.
Patients were divided into three
groups based on operative time
shorter, ideal, and longer
operative time.
Primary endpoint
estimate the ideal operative time range.
Secondary endpoint
Materials and Methods
AIM OF STUDY
estimate the ideal operative time range.

5. Operative time was defined as the time from skin incision to complete skin closure
successful conduct of surgery was defined using nine clinical parameters, as follows:
(i) reduced intraoperative blood loss (mL),
(ii) no intraoperative transfusion,
(iii) no postoperative complications,
(iv) early discharge,
(v) no event of readmission within 30 d,
(vi) early onset of postoperative diet,
(vii) adequate number of retrieved lymph nodes,
(viii) minimal drop in serum albumin level (mg/dL), and
(ix) slight change in body mass index (BMI, kg/m2) at 1 month postoperation.
When surgery simultaneously satisfied all
nine parameters, it was defined as an
uneventful, perfect surgery.
Ideal operative time range

6. Based on the analysis done on collected data the values of the following clinical
parameters was clinically significant to be consider as criteria of conduct surgery :
• blood loss ≤50 mL.
• hospitalization ≤7 d.
• start of postoperative diet ≤4 d.
• number of retrieved LNs ≥40.
• decline in serum albumin level ≤0.4 mg/dL.
• decrease in BMI ≤1.4 kg/m2 at 1 month postoperatively.
Ideal operative time range

7. Blood loss, mL ≤50 226 (56.9) 171.0±42.5 <.001
>50 171 (43.1) 198.3±43.3
Surgical complications None 353 (88.9) 179.5±43.3 <.001
Yes 44 (11.1) 208.9±49.7
Hospitalization duration, d ≤7 d 201 (50.6) 174.8±45.3 <.001
>7 d 196 (49.4) 191.0±43.0
Readmission event None 377 (95.0) 180.0±42.6 <.001
Yes 20 (5.0) 234.3±56.6
Starting day of diet ≤4 d 349 (87.9) 182.4±45.2 <.001
>4 d 48 (12.1) 185.3±43.4
Albumin change, mg/dL ≤0.4 251 (63.2) 177.7±41.9 .005
>0.4 146 (36.8) 191.4±48.5
Variable Number (%) Mean±SD or Median (range) P value

8. Factors contributed to the highest percentage of uneventful surgeries to meet all nine criteria of
uneventful surgeries , even within the shorter operative time range are :
The ability to retrieve a higher number of LNs
annual experiences of gastrectomy for >150 cases
institutions with annual experience of <50 cases could not achieve uneventful surgeries.
overcoming the learning curve for laparoscopic distal gastrectomy requires at least 60–90 cases per year
Kunisaki C, Makino H, Yamamoto N, Sato T, Oshima T, Nagano Y et al.
Learning curve for laparoscopy-assisted distal gastrectomy with regional lymph node dissection for early gastric
cancer.2008

9. 23 PATIENTS WHO SATISFIED ALL NINE PARAMETERS
WERE ANALYZED SEPARATELY.
THE OPERATIVE TIME OF THE 23 CASES WITH
UNEVENTFUL SURGERIES WAS 90–235 MIN
This operative time range also included patients with
unsuccessful operations

10. • We separately collected and analysed patients with
uneventful surgery ; and the 95% confidence interval (CI)
for the mean operative time 135.4 to 165.4
• we additionally calculated the ideal operative time range
based on mean±SD,; 115.8 -185

12. Based on the ideal operative time range (135.4–165.4 min), the patients were divided into three groups :
SHORT
N = 67
IDEAL
N = 80
LONGER
N = 250

13. Clinical outcomes SOT group1) (N=67)
P value 1) vs 2
)
IOT group2) (N=80)
P value 2) vs 3
)
LOT group3) (N=250)
P value 3) vs 1
)
Cases of uneventful, perfect surgery n (%) 9 (13.4) 0.430 7 (8.8) 0.048 7 (2.8) 0.002
Blood loss, mL Median [range] 26 [4, 200] 0.001 50 [4, 300] 0.035 60 [6, 500] <0.001*
Transfusion n (%) 0 (0) 0.406 0 (0) 0.325 3 (1.2) 0.368
Postoperative complications n (%) 2 (3.0) 0.455 5 (6.2) 0.046 37 (14.8) 0.006
Wound 0 (0) - 0 (0) 0.342 6 (2.4) 0.349
Fluid collection 1 (1.5) 0.456 0 (0) 0.207 8 (3.2) 0.690
Intra-abdominal bleeding 1 (1.5) 0.899 1 (1.2) 0.972 3 (1.2) 0.849
Luminal bleeding 0 (0) 0.358 1 (1.2) 0.566 2 (0.8) 0.463
Motility disorder 0 (0) - 0 (0) 0.341 5 (2.0) 0.588
Delayed emptying 0 (0) 0.501 2 (2.5) 0.635 4 (1.6) 0.582
Stenosis 0 (0) - 0 (0) 0.571 1 (0.4) 0.604
Major complications (CD≥ Grade IIIa) n (%) 1 (1.5) 0.677 2 (2.5) 0.260 16 (6.4) 0.137
Hospitalization days Mean ± SD 7.7 ± 2.8 0.120 8.6 ± 4.6 0.028 10.3 ± 6.4 0.001
Re-admission event n (%) 1 (1.5) 0.667 2 (2.5) 0.179 17 (6.8) 0.136
Diet starting days Mean ± SD 2.7 ± 1.3 0.013 3.2 ± 1.2 0.594 3.3 ± 2.1 0.003
Number of retrieved lymph nodes Mean ± SD 39.7 ± 14.0 0.504 37.9 ± 17.8 0.202 40.7 ± 16.4 0.589
Albumin (mg/dL) change Median [range] -0.30 [-1.1, 0.5] 0.099* -0.30 [-1.8, 0.4] 0.576 -0.38 [-3.5, 0.9] 0.091*
BMI (kg/m2) change Mean ± SD -1.4 ± 1.3 0.892 -1.4 ± 1.1 0.310 -1.5 ± 1.0 0.521

14. Causes and impact of longer operative time

15. The shorter the operative time for laparoscopic distal gastrectomy the lower the rate of intraoperative
and postoperative complications .
Considering that laparoscopic experts require a shorter time to complete this essential procedure than
do non-experts.
longer operative times (>165.4min)should be avoided to prevent worse clinical outcomes.
In particular, an operative time exceeding 240 min cannot achieve uneventful surgery.
Conclusions

16. Thank you
Future recommendations
• Efforts to minimize operative time should be
attempted with sufficient surgical experience.
• A wider adoption of this recommendation
should be considered in clinical practice.