Impact of laparoscopic D2 gastrectomy on long-term survival for early gastric cancer

Abstract

There has been a dramatic increase in the clinical use of laparoscopic gastrectomy for the treatment of early gastric cancer within a decade after its introduction in East Asia, particularly Korea [1]. There are several reasons that explain the rapid progress of laparoscopic D2 gastrectomy in Korea. These include the overall, high incidence of gastric cancer, the high rate of diagnosis at early stage, and the increasing number of high-volume hospitals and highvolume surgeons in laparoscopic gastrectomy in Korea. However, in an absence of both randomized, controlled trials and long-term, follow-up data, there is skepticism on a potential negative effect of laparoscopic gastrectomy on oncological outcomes. Lee et al. [2], in a recent issue of Surgical Endoscopy, reported on long-term results after laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer. This study comes to bridge the gap in the absence of long-term outcomes data. The authors analyzed the clinicopathologic data of 106 patients who underwent LADG and compared these results with those of 105 patients who underwent open distal gastrectomy (ODG) for early gastric cancer. The results on early postoperative outcomes are consisted with the literature and confirm the superiority of LADG vs. ODG regarding postoperative recovery, passing flatus, starting a liquid diet, and postoperative hospital stay and postoperative complications [3, 4]. The interest of this study is focused on long-term results. There was no significant difference in overall 5-year survival rate (5-YSR) between patients who underwent LADG (95.9%) and patients who had an ODG (94.9%). These survival results can be considered as excellent given that in the LADG group 6.6% of patients had lymph node metastasis and 37.7% of patients had a submucosal cancer, which both associated its less favorable survival than patients with mucosal and node-negative disease did. In Japan and Korea, two countries with high gastric cancer incidence and large experience with extended lymphadenectomy, open D2 gastrectomy has been the standard of care for localized gastric cancer. Compared with the treatment of gastric cancer in the west, results for early detection and survival are much better in Japan and Korea: 50% vs. \20% early-stage gastric cancer, and [60% vs. \40% overall survival after potential curative gastrectomy respectively in these two countries and western world [5, 6]. Two pivotal studies for advanced stage II/III gastric cancer from Japan have been published recently in the New England Journal of Medicine [7, 8]. The first phase III, adjuvant, randomized, controlled trial, compared D2 lymphadenectomy alone or D2 plus paraaortic nodal dissection (PAND). No patient received adjuvant treatment; Sasako et al. [7] reported the best global 5-year survival results of approximately 70% in both groups. Given that no survival benefit derived from D2 plus PAND, D2 surgery has been the standard approach. The second, a phase III adjuvant randomized trial compared D2 surgery alone vs. D2 surgery plus postoperative S-1 adjuvant chemotherapy. The study stopped due to a significant difference at 3-year survival rate in favor of S-1 chemotherapy in the planned interim analysis. D2 plus S-1 postoperative chemotherapy is the standard treatment for stage II/III gastric cancer in Japan. However, similar results, with exception survival of early gastric cancer [9, 10], have not yet been achieved in Europe or the United States. Indeed, in the west, although quality of surgery plays a predominant role for favorable D. Kanellos I. Kanellos (&) 4th Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece e-mail: ik@hol.gr