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Editorial The current status of Laparoscopic surgery for gastric cancer XI Hong-qing, CUI Jian-xin, CHEN Lin Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing 100853, China Corresponding author: CHEN Lin, Department of General Surgery, Chinese People’s Liberation Army General Hospital, 28 Fuxing Road, Beijing 100853, China. E-mail: [email protected] Telephone: +86-10-66938128 Fax: +86-10-68181689 Funding This work was supported by the National Nature Science Foundation of China (No. 81272698, 81101883, 81172368), the Grant from the Committee of Science and Technology of Beijing, China, (No.Z111107058811047), and the Special Scientific Research Fundation of of health sector from National Health and Family Planning Commission of China (No. 20130206). The funding bodies had no role in study design, data collection or analysis, decision to publish, or preparation of the manuscript. Surgical resection remains the mainstay of curative treatment for gastric cancer. Laparoscopic surgery is a form of minimally invasive surgery (MIS) that has become increasingly used in the resection of gastric cancer. Laparoscopic surgery is designed to minimize surgical insults and to maximize patient survival, while not compromising oncologic clearance. Epidemiology and therapy of gastric cancer Gastric cancer is one of the most common types of malignant tumors in the world and is the second leading cause of cancer deaths worldwide.1 Approximately one million patients are diagnosed every year.2 with over 70% in developing countries.3 The highest incidence rates are in eastern Asia, especially in China. Despite advances in diagnostic tools and multimodality therapy, the 5-year survival rate for all patients with all stages remains less than 30%.4 Therapy can include surgery, chemotherapy, radiotherapy, and/or immunotherapy, with surgical resection being the only potentially curative treatment for gastric cancer. Although previously using a uniform D2 or more extensive surgery, surgical treatment has developed into a tailored and individualized approach, depending on the stage of the disease. In China, most gastric cancer patients are already in an advanced stage at diagnosis, leading to the adoption of a comprehensive, multidisciplinary therapeutic strategy based on surgical treatment. Laparotomy, the previously used surgical modality, was associated with high rates of postoperative complications and poor quality of life. Minimally invasive surgery (MIS) was designed to reduce complication rates and to improve postoperative quality of life. Laparoscopic gastrectomy (LAG) in the treatment of gastric cancer Laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer was initially introduced in eastern Asia in 1994.5 Since then, LADG has been adopted widely for the resection of gastric cancer. Laparoscopic surgery for gastric cancer was designed to minimize surgical insults and to maximize patient survival, while not compromising oncologic clearance. Since the incidence of gastric cancer is lower in western countries, the development of laparoscopic gastric surgery was slower in these countries than in Japan and Korea. The first laparoscopic distal gastrectomy using Billroth II anastomosis for gastric cancer was performed in 1993, with the first laparoscopic total gastrectomy performed 2 years later.6,7 A prospective, randomized trial indicated that the laparoscopic approach was safe and feasible for western patients, with a 5-year survival rate similar to that of open surgery.8 To date, six randomized clinical trials (RCTs) worldwide have assessed the efficacy and safety of laparoscopic surgery for gastric cancer.8-13 In addition, many case-controlled studies and case series have been performed in eastern Asia, especially in Japan and Korea. All the RCTs showed that there was no recurrence of gastric cancer during follow-up in patients who had undergone LADG. A retrospective, multicenter study of 1294 Japanese gastric cancer patients, evaluating the short- and long-term outcomes of LADG for early gastric cancer (EGC) found that LADG was safe, with survival outcomes comparable to those of conventional open surgery.14 Although many retrospective studies supported these findings, these results were not sufficient to draw a definite conclusion because of the small number of patients enrolled. Several recent multicenter trials have evaluated outcomes in patients undergoing LADG for gastric cancer. For example, a phase II trial performed by the Japan Clinical Oncology Group (JCOG 703) found that LADG, when performed by experienced surgeons, was safe in patients with stage I gastric cancer.15 This led to a phase III trial (JCOG 0912), currently ongoing, to confirm the noninferiority of LADG to open gastrectomy with regard to overall survival. Furthermore, a multicenter phase III trial comparing the short- and long-term outcomes of LADG and open distal gastrectomy (ODG) in patients with stage I gastric cancer, performed by the Korean Laparoscopic Gastrointestinal Surgery Study Group (KLASS), found no significant differences between groups in morbidity and mortality rates.13 Final results of the latter trial are still pending. LADG with lymph node dissection has been adopted and widely used in Japan and Korea for patients with EGC and a low risk of lymph node metastasis. As laparoscopic experience has accumulated, the indications for laparoscopic gastrectomy (LAG) have been broadened to include patients with advanced gastric cancer. Because few studies to date have assessed the long-term outcomes of LADG, this surgical method has been accepted by the American Joint Committee on Cancer (AJCC), but not by the National Comprehensive Cancer Network (NCCN), in the resection of EGCs. However, the NCCN recommends preoperational laparoscopic staging. It is unclear whether laparoscopic resection can be safely extended to patients with advanced gastric cancer, since little is known about the long-term outcomes of laparoscopy-assisted total gastrectomy (LATG) and LADG in these patients, including the feasibility and safety of LATG with extended lymphadenectomy in patients with advanced gastric cancer (AGC). Recently, the KLASS launched a phase III trial assessing LATG in patients with AGC. A meta-analysis,16 comparing clinical outcomes in patients with AGC showed that total and partial laparoscopic gastrectomy was associated with a longer operation time but lower blood loss and shorter postoperative hospital stay than open gastrectomy. Moreover, the outcomes in patients with dissected lymph nodes and those in long-term survival patients were similar. However, only one of the seven studies included in the meta-analysis was a prospective RCT, with the other six being retrospective ones, and the total number of patients included was relatively small. Additional studies are needed to standardize the LAG method and to determine the feasibility, safety and short- and long-term outcomes of LAG for AGC. A large-scale multicenter retrospective study by the KLASS showed that long-term survival outcomes of LAG for AGC were comparable to those previously reported for open gastrectomy.17 The Chinese Medical Association has recommended that LAG be limited to gastric cancer without involvement of the serosa, whereas tumors with serosa involvement (< 10cm2) should undergo LAG only in the context of a clinical trial and only in specific medical centers with sufficient professional experience.18 Methods being tested to improve the resection, meticulousness and feasibility of LAG for AGC include a robotic approach, an improved energy platform, a 3D-imaging system, and more attention to cultivating team members. Robotic-assisted laparoscopic gastrectomy in the treatment of gastric cancer Robotic-assisted laparoscopic gastrectomy is a novel treatment approach for gastric cancer. This approach may show more benefits than laparoscopic gastrectomy in practice but may encounter the same problems. The da Vinci Surgical System is characterized by: a three-dimensional, ten-fold magnified vivid view of the operating field; instruments with articulating end effectors and seven degrees of freedom; tremor filtering; motion scaling; all of these may help surgeons to overcome the limitations of conventional laparoscopic surgery.19 Since robotic-assisted distal gastrectomy with lymph node dissection was first described in 2002,20 several studies worldwide, especially in Japan, Korea, and Italy, were designed to assess the feasibility and safety of this procedure. The use of a surgical robot in GC resection has been associated with a longer operation time, reduced blood loss, and shorter hospital stay, which are consistent with the results in our center. However, the economic feasibility of robotic devices for gastrectomy remains unclear. Limited experience and evidence remain the major stumbling blocks to the widespread use of this procedure. Conclusion MIS may be as effective as conventional open surgery if basic surgical principles are strictly followed. These include proper indications, sufficient surgical margins, standardized D2 lymphadenectomy, and the use of a no-touch technique. Well-designed, prospective, multicenter RCTs are also needed to compare laparoscopic with conventional open surgery. LAG may become a standard therapeutic approach for gastric cancer and may play an important role in the resection of gastric cancers in the future. References 1. Parkin DM, Bray F, Ferlay J, et al. Global cancer statistics. 2002. CA Cancer J Clin 2005;55:74-108. 2. Shah MA, Kelsen DP. Gastric cancer: a primer on the epidemiology and biology of the disease and an overview of the medical management of advanced disease. J Natl Compr Canc Netw 2010; 8(4):437-447 3. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin 2011;61(2):69-90. 4. 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