Facts and trends in laparoscopic gastrectomy for cancer

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The past few years have seen an explosion of interest in laparoscopic gastrectomy for gastric cancer. In Korea, this interest has already been translated into wider clinical use. Large-scale retrospective studies and randomized controlled trials from Korea have currently been published [1, 2]. The trend also is increasing in Japan, China, and other Asian countries. What are the requirements, risks, and benefits of this modern surgical approach in the West? Can laparoscopic gastrectomy be widely used outside Korea? In a recent online first publication in Surgical Endoscopy, Yoo et al. [3] reported on the complications associated with laparoscopically assisted distal gastrectomy (LADG) used to treat early gastric cancer. What is new in this study, and why is it of major interest for Western surgeons? The LADG procedure was performed by a single experienced gastric surgeon who initially had no experience with laparoscopic surgery compared with open distal gastrectomy (ODG). Therefore, this study shed light on the issue of whether a Western surgeon experienced in open gastrectomy can safely and effective perform an LADG after an initial learning curve. Within 12 months (January 2006–December 2007), 102 patients underwent LADG; 4 patients had open conversion; and 71 patients underwent conventional ODG. All the patients had an early distal gastric cancer (cT1N0M0). The operation time was significantly longer for the LADG group, but the postoperative hospital stay was significantly shorter for this group than for the ODG group. There was no significant difference in the overall complication rates between the LADG and ODG groups. To assess the impact of the learning curve on outcomes, the authors compared the first 50 with the last 52 LADGs. The operation time and postoperative hospital stay were shorter, and the number of retrieved lymph nodes was greater in the late group (p \ 0.05). The major and minor complications were markedly reduced in the late group (p \ 0.05). The authors confirm the safety and efficacy of LADG, but they emphasize the importance of the learning curve in achieving better short-term clinical outcomes. What are the implications of this study? The study adds more data supporting LADG for early gastric cancer. The major advantage of this study is the very large number of patients with early gastric cancer (n = 177) who were treated at this single hospital within a short period (1 year). However, exactly this fact reflects the limitations for other countries. For example, many patients with early gastric cancer in Japan would be treated with endoscopic mucosal resection rather than LADG. These patients have met specific criteria, namely, mucosal cancer less than 2 cm in large diameter and of a differentiated histologic type [4, 5]. In the Western world, the rate of early gastric cancer is low, and sample sizes similar to that reported from Korea are unrealistic. Thus, learning will require too long a time, and this may explain why in the few reports available, LADG includes also patients with advanced disease. In the Western world, where evidence-based medicine is considered essential, the retrospective nature of the study by Yoo et al. [3] limits the clinical implication of LADG. What about the extent of lymphadenectomy? In the absence of positive randomized controlled trials, the clinical utility of extended D2 lymphadenectomy in the United States and Europe has long been debated [6–11]. D. Kanellos M. G. Pramateftakis I. Kanellos (&) Fourth Surgical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece e-mail: ik@hol.gr