Abstract
Dear Editor, We read with great interest the article by Memon et al. [1] published in the August 2008 issue of Surgical Endoscopy. This meta-analysis compares laparoscopically assisted distal gastrectomy (LADG) with open distal gastrectomy (ODG) for gastric cancer located in the distal two-thirds of the stomach. The LADG procedure has been popular with gastrointestinal surgeons recently, and several randomized controlled trials (RCTs) on this topic have emerged. The authors include four published RCTs for the pooled estimates and meaningfully conclude that the LADG technique appears safe and offers some advantage in postoperative recovery. However, we noted that one of the four RCTs [2] included in the metaanalysis was obviously different from the others in stage proportion. This RCT enrolled patients of any stage unselectively, whereas the other three RCTs included only patients with preoperative cT1 diseases. In that unselective RCT, merely 20.8% of the LADG patients and 23.3% of the ODG patients had pT1 disease. Therefore, might this heterogeneity of patients not bias the judgment of the outcomes by more advanced diseases? According to the oncologic principle, is the application of LADG for advanced gastric cancer acceptable currently? Additionally, with regard to the survival outcome, only the unselective RCT [2] reported the 5-year overall disease-free survival rate, which apparently was lower than those of the early gastric cancer (EGC) series [3]. The other three RCTs, enrolling mostly patients with EGC, present no recurrence case in their follow-up periods. Furthermore, they are limited to proving the long-term effectiveness of LADG by short follow-up periods ranging from 14 to 39 months. In addition, the number of harvested lymph nodes is significantly reduced in LADG. Hence, is the pooled estimate of tumor recurrence appropriate? Would the long-term survival benefits of LADG for EGC really be satisfactory? Concerning the reconstruction pattern of the digestive tract, the three RCTs in the metaanalysis that enrolled the patients with EGC adopted the approach of Billroth I reconstruction in the LADG procedure. To our knowledge, Roux-en-Y anastomosis technically is feasible in LADG. The RCT that adopted Roux-en-Y or Billroth II in both LADG and ODG did not significantly increase the rate of morbidity or mortality [2]. Nunobe et al. [4] documented that both symptomatically and functionally, the postoperative quality of life with Roux-en-Y reconstruction is superior to that of the Billroth I method 5 years after ODG for EGC. Therefore, may not the application of Roux-en-Y reconstruction in LADG be better for patients with EGC?
Published Version
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