Reduced port surgery for gastric cancer: another giant leap for mankind?

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According to a nationwide survey conducted by the Japanese Society for Endoscopic Surgery, there has been a steep rise in the number of laparoscopic gastric cancer surgeries performed in Japan during the past decade. Innovations in surgical devices and video cameras, refinement of the surgical technique, and easy access to various types of information associated with the new approach have enabled an increasing number of surgeons to safely add laparoscopic gastrectomy to their armamentarium. In Japan, after the first successful attempt by Kitano et al. [1] to perform distal gastrectomy laparoscopically, consistent efforts had been exerted by a small number of the so-called first-generation laparoscopic surgeons to improve the technique and to conduct the procedure safely with curability that was hoped not to be inferior to the conventional open surgery. The guideline-oriented surgical procedure for patients with early gastric cancer has been designed to obtain arguably an overly cautious safety margin in terms of nodal dissection so that the cure rate would be as close to 100 % as possible. Thus, most patients in this category are likely to be cured even if subjected to technically immature surgery. The high incidence of earlystage cancer in Japan meant that surgeons were able to rapidly acquire sufficient experience and expertise in the laparoscopic approach without having too much concern about the long-term outcome. Representative members of the first generation of surgeons eventually compiled and published retrospective data that indicated the feasibility and benefits of this approach [2]. In due course, these selected surgeons were invited to join the gastric cancer surgery division of the Japan Clinical Oncology Group (JCOG), the most distinguished multi-institutional study group in Japan, funded by the Ministry of Health, Labor and Welfare, to conduct trials and establish the place of laparoscopic surgery as a treatment option for early (T1 stage) gastric cancer. However, the time needed to conduct a preparative phase II study to investigate at the safety of the procedure [3] and then to design a subsequent phase III trial to evaluate the oncological outcome was too great for these celebrated laparoscopic surgeons to remain loyal to the policy of the JCOG. By the time the JCOG phase III trial was launched, advocates of laparoscopic surgery no longer felt comfortable treating 50 % of their patients with the open approach, particularly when their patients visited them expecting to receive laparoscopic surgery. In the mean time, high-volume centers in Japan gradually added laparoscopic gastrectomy to their repertoire either through headhunting an established expert or by having their staff go through training programs with the assistance of experts from another institution. Two examples of such processes have been documented in recent volumes of Gastric Cancer [4, 5]. The aforementioned JCOG phase III trial is currently ongoing in the hands of these and other ‘‘second-generation’’ surgeons who had once been dedicated open surgeons but have striven hard more recently to become board certified as laparoscopic surgeons. Thus, the situation in Japan is steadily changing and, although the Japanese Gastric Cancer Treatment Guidelines remain cautious about the role of laparoscopic approach, an increasing number of surgeons would now consider laparoscopic gastrectomy as their standard treatment for early cancer of the distal stomach. Some This editorial refers to the article doi:10.1007/s10120-012-0212-z.