Download View PDF

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. Thun MJ, DeLancey JO, Center MM, Jemal A, Ward EM. The global burden of
cancer: priorities for prevention. Carcinogenesis 2010; 31: 100-110.
5. Kitano S, Iso Y, Moriyama M, Sugimachi K. Laparoscopy-assisted. Billroth-I
gastrectomy. Surg Laparosc Endosc 1994;4:146–148.
6. Azagra JS, Goergen M, De Simone P, Ibañez-Aguirre J. Minimally invasive
surgery for gastric cancer. Surg Endosc 1999;13(4):351–357.
7. Azagra JS, Goergen M, Gilbart E. Laparoscopy-assisted total gastrectomy with
extended lymphadenectomy for cancer: technical aspects. Le Jour Coeliochir
2001;40:35–36.
8. Huscher CG, Mingoli A, Sgarzini G, Sansonetti A, Di Paola M, Recher A, et al.
Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: five-year
results of a randomized prospective trial. Ann Surg 2005;241(2):232–237.
9. Kitano S, Shiraishi N, Fujii K, Yasuda K, Inomata M, Adachi Y. A randomized
controlled trial comparing open vs laparoscopy-assisted distal gastrectomy for the
treatment of early gastric cancer: an interim report. Surgery 2002;131:S306–311.
10. Lee JH, Han HS. A prospective randomized study comparing open vs
laparoscopy-assisted distal gastrectomy in early gastric cancer: early results. Surg
Endosc 2005;19:168–173.
11. Hayashi H, Ochiai T, Shimada H, Gunji Y. Prospective randomized study of open
versus laparoscopy-assisted distal gastrectomy with extraperigastric lymph node
dissection for early gastric cancer. Surg Endosc 2005;19:1172–1176.
12. Kim YW, Baik YH, Yun YH, Nam BH, Kim DH, Choi IJ, et al. Improved quality
of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric
cancer: Results of a prospective randomized clinical trial. Ann Surg
2008;248:721–727.
13. Kim HH, Hyung WJ, Cho GS, Kim MC, Han SU, Kim W, et al. Morbidity and
mortality of laparoscopic gastrectomy versus open gastrectomy for gastric cancer:
An interim report-A phase III multicenter, prospective, randomized Trial (KLASS
Trial). Ann Surg 2010;251:417–420.
14. Kitano S, Shiraishi N, Uyama I, Sugihara K, Tanigawa N, Japanese Laparoscopic
Surgery Study Group. A multicenter study on oncologic outome of laparoscopic
gastrectomy for early cancer in Japan. Ann Surg 2007;245:68–72.
15. Katai H, Sasako M, Fukuda H, Nakamura K, Hiki N, Saka M, et al. Safety and
feasibility of laparoscopy-assisted distal gastrectomy with suprapancreatic nodal
dissection for clinical stage I gastric cancer: A multicenter phase II trial (JCOG
0703). Gastric Cancer 2010;13:238–244.
16. Martínez-Ramos D, Miralles-Tena JM, Cuesta MA, Escrig-Sos J, Van der Peet D,
Hoashi JS, et al. Laparoscopy versus open surgery for advanced and resectable
gastric cancer: a meta-analysis. Rev Esp Enferm Dig 2011;103(3):133-141.
17. Park do J. Han SU, Hyung WJ, Kim MC, Kim W, Ryu SY, et al. Long-term
outcomes after laparoscopy-assisted gastrectomy for advanced gastric cancer: a
large-scale
multicenter
retrospective
study.
Surgical
endoscopy
2012;26:1548-1553.
18. Chinese Medical Association. Operation Manual of Laparoscopic Surgery for
Gastric
Malignant
Tumor
(Version
2007).
J
Surg
Concept
s
Pract
2007;12(6):610-614.
19. Uyama I, Kanaya S, Ishida Y, Inaba K, Suda K, Satoh S. Novel integrated robotic
approach for suprapancreatic D2 nodal dissection for treating gastric cancer:
technique and initial experience. World J Surg 2012;36:331-337.
20. Hashizume, M. Shimada M, Tomikawa M, Ikeda Y, Takahashi I, Abe R, Koga F,
et al. Early experiences of endoscopic procedures in general surgery assisted by a
computer-enhanced surgical system. Surgical endoscopy 2002;16:1187-1191.