Proximal gastric cancer: advances of laparoscopic surgery

Abstract

Although the overall incidence of gastric cancer is decreasing, gastric cancer still remains the fourth most common cancer worldwide. The decrease in the incidence rate varies considerably depending on the geographical area. For example, gastric cancer is continuously the most common cancer type in Asian countries such as Japan, Korea, and China, with a slow and slight drop in the prevalence of the disease in these countries. There has been a greater decrease in the incidence curve over the last few decades in the USA and northwest Europe, but the prevalence of proximal and gastroesophageal junction cancer in these areas is increasing. Therefore, there is interest in how to manage patients with upper-third stomach cancer to improve oncological and quality-of-life (QOL) outcomes not only in the Eastern but also in the Western world. The Aihara et al. [1] report in the September issue of Surgical Endoscopy provides useful information for the laparoscopic surgical treatment of patients with proximal gastric cancer. The authors describe a technique of laparoscopy-assisted proximal gastrectomy (LAPG) and gastric tube reconstruction using a miniloop retractor (MLR). The feasibility and safety of this technique was evaluated in 44 patients with early-stage upper gastric carcinoma. Five surgical ports were inserted into the abdomen and the stomach was lifted to the abdominal wall side with a MLR. Reconstruction with a gastric tube (20 cm long, 3 cm wide) using a circular stapler was performed through a small incision, through which the specimen was removed. The mean operating time was 202 min. There were no serious complications no deaths, and no conversions to open surgery. The authors concluded that this technique of LAPG and gastric tube reconstruction using MLR is feasible and safe for the treatment of proximal early gastric cancer. The data provided by Aihara et al. [1] support the safety of their technique, which is technically more complicated than laparoscopy-assisted distal gastrectomy (LADG). The incidence of early gastric cancer (EGC) in Japan and Korea is high and approximately 50% of cases are diagnosed at this early stage through established nationwide endoscopic screening. These high EGC rates have led to the development and validation of minimally invasive approaches, including endoscopic submucosal dissection (ESD) and laparoscopic surgery in these countries. Criteria for clinical decision-making on ESD, laparoscopic gastrectomy, or open surgery have been defined by Japanese scientific associations. There is now an explosion in laparoscopic surgery for the treatment of gastric cancer in Asian countries and also an increase in the use of this minimally invasive approach in some specialized centers in the West [2]. Based on strong evidence of the superiority of laparoscopic versus open surgery with respect to quality of life for colorectal cancer patients [3] and accumulating evidence, although still incomplete, for early gastric cancer patients [4–6], the technique of laparoscopic gastrectomy has evolved rapidly. Now, the evolution includes totally intracorporeal laparoscopic distal, proximal, or total gastrectomy with standardized extended D2 lymphadenectomy, and indications for its use have been expanded to include patients with advanced resectable stage II and stage III disease [2]. Survival benefits of D2 surgery [7] are now being confirmed by the long-term 15 year survival results of a Dutch trial [8]. This assessment of D2 surgery gains in open surgery makes this standardized lymphadenectomy an C. Batsis (&) Department of Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, TK, Greece e-mail: chbatsis@hotmail.com