Background
Gastric adenocarcinoma is the fourth leading cause of cancer deaths in the United States and affects roughly 22,000 patients in the United States per year, with more than 14,000 deaths annually.
Despite advances in multimodality therapy for gastric cancer, along with resection for curative intent, recurrence and mortality remains high. This may in part be due to the late stage at which the diagnosis is made. In countries such as Japan, South Korea and China, death rates from gastric cancer range between 38-55 patients per 100,000
population. In the United States the incidence of gastric cancer is lower but remains at 1:100,000 per year. Japanese and Korean investigators developed both screening techniques and minimal access approaches to treatment of early gastric cancers. In the United States, much fewer patients present with early stage disease.
Laparoscopic Approach for Advanced Gastric Cancer
Controversy persists regarding the laparoscopic approach for various oncologic procedures, although support and evidence for the minimally invasive approach is
growing (Weeks JC, Nelson H, Gelber S, Sargent D, Schroeder G, JAMA. 2002 Jan 16;287(3):321-8; Strong VE, D’Angelica M, Tang L, Prete F, Gonen M, Coit D, Touijer
K, Fong Y, Brennan M. Ann Surg Oncol, 14(12):3392-400, 2007).
Laparoscopic approaches for gastric cancer, in particular, have been more slowly accepted, largely due to the lower incidence of gastric cancer in the West and the
presentation at more advanced stages. Therefore, although the role of laparoscopic gastric surgery in the West has developed with general acceptance for the treatment of benign conditions such gastroesophageal reflux and morbid obesity, the role of laparoscopic surgery for the treatment of malignant gastric disease remains less clear.
In 1994, Kitano performed the first laparoscopic assisted distal gastrectomy (LADG) with a modified D1 lymph node dissection (D1 + Left gastric artery group and
D1 + common hepatic artery group) for the treatment EGC with high risk of lymph node metastasis. This demonstrated the utility of laparoscopic surgery for gastric malignant
disease in the East with regard to feasibility of an oncologically appropriate laparoscopic lymphadenectomy.
The development of laparoscopic surgery for malignant gastric disease in the West has been slower. This is partly related to skepticism regarding oncologic results for
this advanced surgical procedure with a significant learning curve.
The Western experience with laparoscopic surgery for malignant gastric tumors had until recently, been primarily confined to diagnostic laparoscopy as an adjunct to
preoperative staging, and stratification of patients for neoadjuvant treatment of locally advanced tumors, and more recently, for gastric LWR for gastrointestinal stromal tumors,
carcinoid tumors and early stage adenocarcinoma. Laparoscopic distal, subtotal and total gastrectomy for early and advanced gastric cancer is now emerging in the West with
progressive acceptance among various groups although this progress has been slowed by the difference in natural history of gastric adenocarcinoma in the East compared to the
West.
In 1996, Azagra et al reported the first laparoscopic total gastrectomy for cancer. Azagra and his group from Belgium have been Western pioneers in minimally invasive
gastric resection for cancer, performing the first totally laparoscopic distal gastrectomy with Billroth II anastomosis for cancer in 1993 and the first reported laparoscopic total
gastrectomy for cancer in 2001. Despite the relatively new advent of these techniques, there has been an aggressive approach to reporting series of patients undergoing
laparoscopic resections for gastric cancers.
Huscher et al from Italy reported in the only prospective randomized trial to date in the West, on 5-year clinical outcomes of laparoscopic-assisted subtotal gastrectomy
compared to open subtotal gastrectomy for stage-matched adenocarcinomas, and demonstrated both safety and feasibility of the laparoscopic approach. Five-year survival
numbers showed no significant difference between the two groups but provided patients of the laparoscopic group with established benefits of minimally invasive surgery.
In the United States, there have been only 4 retrospective trials looking at laparoscopic gastrectomy for gastric cancer. The largest of these series include the recent
publications from Memorial Sloan-Kettering Cancer Center and the City of Hope Cancer Center, where in each series, 30 laparoscopic gastrectomies were performed and then
compared to case-matched open gastrectomies.
A recent review of the gastrectomy experience at City of Hope and a separate review of the gastrectomy experience at Memorial Sloan-Kettering Cancer Center
enables a comparison of MIG and OG. In the City of Hope experience, a total of 78 consecutive patients were evaluated, including 30 MIG and 48 OG procedures. There was
no difference in the mean number of lymph nodes retrieved by MIG or OG (24 ± 8 vs. 26 ± 15, P = .66). MIG procedures were associated with decreased blood loss (200 vs.
383 mL, P = .0009) and length of stay (7 vs. 10 days, P = .0009), but increased operative time (399 vs. 298 minutes, P < .0001). Overall complication rate following MIG was
lower but statistical significance was not achieved.
In the Memorial Sloan-Kettering Cancer Center experience, a total of 60 patients were evaluated, including 30 MIG and 30 OG procedures. Median operative time for the
laparoscopic approach was 270 min compared with a median operative time for the laparoscopic approach was 270 (range 150-485) compared to 126 minutes (range 85-205)
in the open group (p< 0.01). Hospital length of stay after laparoscopic gastrectomy was 5 days (range 2-26), compared to 7 days (range 5-30) in the open group (p= 0.01). Post
operative IV narcotic use was shorter for laparoscopic patients, with a median of 3 days (range 0-11) compared to 4 days (range 1-13) in the open group (p< 0.01). Post-operative
late complications were significantly higher for the open group (p=0.03). Short-term recurrence-free survival and margin status was similar with adequate lymph node retrieval in both groups. This series concluded that laparoscopic gastrectomy for carcinoma is comparable to the open approach with regard to oncologic principles of
resection, with equivalent margins and adequate lymph node retrieval, demonstrating technically feasibility and similar short-term recurrence-free survival.
Conclusion
Open gastrectomy with a minimal lymph node dissection of 15 for staging purposes remains an appropriate surgical treatment for gastric adenocarcinoma in the
West. With increasing experience and expertise of oncologic surgeons in the minimally invasive approach to gastric resection for cancer, it is becoming evident that laparoscopy
as a technique for resection, provides equivalent resections with equivalent lymphadenectomy comparable to the open approach with no compromise in recurrence or
long-term survival based on preliminary studies. In addition, based on the known benefits of the minimally invasive approach including reduced surgical trauma, blood loss, pain
and quicker recovery for the patient, we are encouraged to expand our indications for this approach. This has been prompted also by advances in minimally invasive surgery for
benign abdominal disease, and the results from multiple Eastern studies of early stage cancer. Although an open approach should be applied in any case where concerns over
local resectability, definition of anatomy or surgeon comfort level is an issue, it appears that this approach is here stay. As the indications continue to expand for more advanced
tumors and with additional prospective studies, we will be able to more clearly define the oncologically appropriate application of laparoscopic gastrectomy.
References
1. Kitano et al, Surgery, 2002, 131:S306-11
2. Huscher et al, Ann Surg, 2005, 241(2):232-237.
3. Hayashi et al, Surg Endosc, 2005, 19:1172-1176.
4. Kim et al, Ann Surg, 2008, 248(5):721-727.
5. Strong et al, Ann Surg Oncol, 2009, 16:1507-1513.
6. Guzman et al, Ann Surg Oncol, 2009, 16(8):2218-2223.