Is laparoscopic gastrectomy safe for western patients with gastric cancer with high body mass index?

Abstract

During the last decade, clinical outcomes of patients with gastric cancer have improved [1, 2]. Both survival and quality of life (QOL) of patients with adenocarcinoma of the stomach can be improved with appropriate treatment [3]. Although disease-free and overall survival have been improved due to standardized D2 gastrectomy [4–11] plus preoperative (neoadjuvant) or postoperative chemotherapy alone or plus radiotherapy [12–14], this improvement for patients with advanced potentially curable stage II and III disease is modest. Adjuvant molecularly targeting therapy for gastric cancer is still considered experimental and despite current limitations, there is hope that the next generation targeted agents will further prolong survival and cure rates for patients with solid cancers, including gastric cancer [15]. In contrast to the small cure rate and slow trend toward improvement, particularly in western countries, QOL has more rapidly and substantially been improved due to minimally invasive techniques, including endoscopic mucosal resection for small, early gastric cancers and laparoscopic surgery for more advanced tumors. The clinical success of laparoscopic gastrectomy in east Asian countries, predominantly Korea and Japan, has started to influence the treatment of gastric cancer. The trend from open to totally laparoscopic gastrectomy in the United States is here [16]. High-volume surgeons and high-volume hospitals in laparoscopic surgery are considered surrogate predictors of safe performance with good QOL outcomes. In an absence of experience with laparoscopic technique and the relatively high body mass index (BMI) of western patients, how safe and efficient is laparoscopic gastrectomy in the west? Given the absence of large-scale data from western studies, information from laparoscopic gastrectomy in Asian patients could be clinically very useful for western surgeons planning future performance of laparoscopic gastrectomy for gastric cancer. Such studies can provide useful information about how to avoid postoperative complications after laparoscopic gastrectomy. Indeed, the large-scale study by Lee and colleagues [17], published recently in Surgical Endoscopy, gives answers to these critical for clinical practice questions. Based, on the clinical data of 1,485 patients with gastric cancer treated by laparoscopy-assisted gastrectomy (LAG) in ten institutions in Korea, the authors evaluated the impact of BMI on postoperative complications. Lee et al. [17] reported that overall there was no statistically significant difference for postoperative morbidity and mortality between the high BMI (15.7 and 0.9%) and low BMI (14 and 0.5%) groups (p = 0.37 and p = 0.29). However, the operation time was significantly longer (242.5 min) and the number of retrieved lymph nodes significantly lower (30.4) in the high BMI group than in the low BMI group (223.7 min and 32.6 nodes (p \ 0.001 and p = 0.005), respectively). Further subgroup analysis according to the surgeon’s volume showed that for surgeons who had performed fewer than 40 LAG procedures, postoperative morbidity in male patients with high BMI was substantially high. The authors suggest a careful approach if the surgeon has limited experience with laparoscopic-assisted gastrectomy, particularly for patients with high BMI. The benefits of QOL outcomes with laparoscopicassisted gastrectomy, and particularly with totally laparoscopic gastrectomy avoiding the disadvantages of minilaparotomy versus open gastrectomy, are clear, therefore, it is expected that totally laparoscopic gastrectomy will D. Kanellos I. Kanellos (&) 4th Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece e-mail: ik@hol.gr