Expanding laparoscopic gastrectomy for gastric cancer outside Korea and Japan

Abstract

During the past four decades, open gastrectomy with D2 lymphadenectomy has been the standard approach for resectable gastric cancer in Japan. But only recently with evidence from western phase 3 randomized controlled trials for the safety and survival benefit of D2 versus D1 surgery [1], D2 surgery can be recommended for wide practical implementation when it results in a complete tumor resection (R0). During the past decade, large retrospective studies and small randomized trials, mostly from Korea and Japan, have reported positive results with laparoscopic surgery mainly for early gastric cancer [2]. However, totally laparoscopic D2 gastrectomy particularly for advanced gastric cancer, is a highly demanded, timeconsuming procedure that requires evaluation in clinical trials for its safety and efficacy considering also cost-benefit analysis compared with standard open D2 surgery [3]. The recent report for laparoscopic D2 gastrectomy for gastric cancer by Moisan and colleagues [4] in the March issue of Surgical Endoscopy comes not from Korea, Japan, or specialized hospitals in the United States or European Union but from Chile. In this country, along with Asia and east European countries, incidence of gastric cancer continues to be high, which may explain advances with laparoscopic surgical treatment. Moisan and colleagues [4] compared early and longterm outcomes of 31 gastric cancer patients who underwent totally laparoscopic D2 gastrectomy (LG) with intracorporeal handsewn esophagojejunostomy between 2003 and 2010 with those of 31 patients who received an open D2 gastrectomy (OG) as the standard group. There were major complications with two vs. no duodenal stump leakages in LG and OG respectively and two esophagojejunostomy anastomotic leakages in each group. After a median followup of 3 years, there was no significant difference in recurrence-free survival or overall survival between the two groups. The authors conclude that laparoscopic D2 surgery is feasible, safe, and as effective as open D2 surgery regarding oncological outcomes. This study provides many positive aspects. Totally laparoscopic gastrectomy with total gastrectomy and D2 lymphadenectomy is a highly demanding procedure that is feasible, safe, and effective with respect to long-term survival only when it is performed by high-volume surgeons with expertise and skill in this technique. The 35 retrieved lymph nodes in the laparoscopic group reveals the standardized and completeness of D2 lymphadenectomy that is essential for locoregional tumor control in advanced lymph node-positive disease. However, some questions raise the relatively high rates of leakages in duodenal stump and esophagojejunostomy. Laparoscopic surgery has evolved rapidly and provides evidence for its superiority for the treatment of colon cancer and positive data for rectal cancer treatment [5–7]. However, at present, totally laparoscopic D2 gastrectomy for advanced potentially curable gastric cancer, despite sporadic reports with enhanced results, requires evaluation within clinical trials and cannot be recommended outside highly specialized hospitals [3]. Although laparoscopic surgery can improve quality of life [8–11], the grand challenge remains of how the cancer genome heterogeneity and complexity of cancer cells in individual patient’s tumors can be overcome. Recently, the addition of trastuzumab to chemotherapy in HER2-positive metastatic or advanced gastric cancer has become the new standard, and new phase 3 trials also may establish its use C. Hottenrott (&) Chirurgische Klinik, St. Elisabethenkrankenhaus, Ginnheimer Strase 3, 60487 Frankfurt, Germany e-mail: info@gastricbreastcancer.com