Gastrectomy for cancer: What are the benefits of a minimally invasive approach?

Gastric cancer is a significant cause of cancer morbidity and mortality in the U.S., with an estimated 26,370 new cases and 10,730 deaths in 2016.1 The incidence of gastric cancer is rising, particularly proximal tumors, and among young (< 40 years old) Caucasians, who have experienced a nearly 70 percent increase in the incidence of gastric cancer in the last few years.2 In addition, more gastric cancers are being identified at an earlier stage, potentially allowing for less invasive approaches to treatment.

Clear advantages of minimally invasive surgery have been demonstrated for some operations, such as cholecystectomy and colectomy. These benefits include decreased postoperative pain, morbidity, recovery time, length of stay, and overall hospital cost. However, for other operations, such as appendectomy, and ventral and inguinal hernia repair, the benefits are less apparent. Do the benefits of a minimally invasive approach translate to gastrectomy for gastric cancer?

Minimally invasive gastrectomy has become the standard of care in Asia, where a higher incidence of gastric cancer and screening programs contribute to a high detection of early-stage gastric cancer.3 Data are less robust in Western populations, where patients typically present with more advanced disease and studies are fewer.4

Distal gastrectomy and early gastric cancer

With respect to distal gastrectomy, multiple trials, including several randomized controlled trials, suggest that laparoscopic-assisted distal gastrectomy (LADG) is associated with decreased intraoperative blood loss, decreased pain scores and length of stay, improved quality of life, and longer operative times.5−7 Notably, these studies predominantly involve patients with small, distal tumors identified during routine screening endoscopy.

The Korean Laparoendoscopy Gastrointestinal Surgery Study (KLASS) Group is a multicenter effort to evaluate the feasibility of LADG versus open distal gastrectomy for early gastric cancer. Initial results showed a decrease in overall complication rate in the laparoscopic group (13 percent versus 20 percent, p = 0.001).7 Major intra-abdominal complications and mortality rates were similar between the two groups.

An important oncologic quality measure is lymph node retrieval. In a recent report from a large randomized controlled trial, the number of lymph nodes retrieved in the LADG group was slightly inferior to open gastrectomy (40.5 versus 43.7, p < 0.001), but was nonetheless sufficient for pathologic staging.7

Meta-analysis of LADG for early gastric cancer has shown no difference in mortality or anastomotic, pulmonary, or wound complications. Despite a longer operative time and a slightly lower lymph node harvest, LADG has been associated with lower morbidity, decreased pain scores, and shortened length of stay, as well as significantly fewer complications and equivalent oncologic outcomes.3,8

One randomized trial in a Western population did demonstrate reduced intraoperative blood loss, earlier resumption of oral intake, and a shorter length of stay for patients who underwent laparoscopic rather than open radical subtotal gastrectomy, with no differences in long-term oncologic outcome.9 A recent retrospective study looking at outcomes of stage-matched laparoscopic and open gastrectomies also found that more patients who required adjuvant treatment for their gastric cancers were able to undergo that treatment after laparoscopic gastrectomy versus open, perhaps suggesting another benefit for minimally invasive approaches in terms of quicker and more complete recovery.4

Advanced gastric cancer and total gastrectomy

Initial results supporting the use of minimally invasive gastrectomy for early gastric cancer have led to its increasing application for treating advanced gastric cancer. Several retrospective studies have suggested that laparoscopic-assisted gastrectomy is associated with less blood loss, decreased hospital stay and pain, decreased early postoperative complications, and no difference in overall survival compared with open gastrectomy.10-12 One randomized trial has compared laparoscopic-assisted gastrectomy with open gastrectomy.13 Although operative duration was longer in the laparoscopic group, pulmonary infection was more frequent in the open group. No difference in morbidity or mortality was noted.

Meta-analyses of laparoscopic-assisted gastrectomy for advanced gastric cancer have demonstrated longer procedure times, decreased intraoperative blood loss, decreased length of stay, similar number of lymph nodes harvested, and decreased complications, as well as no difference in overall or disease-free survival between laparoscopic-assisted gastrectomy and open gastrectomy.3,14,15

Selection for minimally invasive gastrectomy

Patient selection is critical for achieving acceptable outcomes with minimally invasive gastrectomy. Important considerations include size and location of the tumor, prior abdominal surgery, patient body habitus, and surgeon experience. Laparoscopic gastrectomy is a technically challenging operation; for distal gastrectomies, it has been suggested that surgeons may need to complete up to 90 cases to achieve proficiency.16 For total gastrectomies, as many as 100 cases may be needed.17

Multiple ongoing randomized trials to evaluate the efficacy of laparoscopic gastrectomy, both for early cancers and for advanced disease, are in process (see Table 1).

Table 1. Ongoing clinical trials in minimally invasive gastrectomy

Trial name, national clinical trial (NCT) ID Patient population Intervention Primary outcome
KLASS-03 trial, NCT01584336 Clinical stage I gastric cancer Laparoscopic-assisted total gastrectomy Morbidity and mortality
KLASS-02 trial, NCT01456598 Locally advanced gastric cancer Laparoscopic versus open gastrectomy Three-year relapse-free survival
JLSSG0901 (phase III) T1-3, N0-2, M0 gastric cancer Laparoscopic-assisted versus open distal gastrectomy Relapse-free survival
CLASS-01 trial, NCT01609309 T2-4a, N0-3, M0 gastric cancer Laparoscopic versus open gastrectomy Three-year disease-free survival rate
Surgical Technique, Open versus Minimally-invasive gastrectomy After Chemotherapy (STOMACH), NCT02130726 T1-3, N0-1 gastric cancer after chemotherapy Minimally invasive versus open gastrectomy Extent of lymph node dissection

Conclusion

A high-quality patient outcome should always take precedence over surgical approach (open versus laparoscopic). However, as surgical experience with minimally invasive techniques grows and as technology advances, it is becoming clear that minimally invasive appropriate resections can play an important role in the care of well-selected gastric cancer patients. The indications for this approach continue to advance and may provide benefits for our patients, not only in faster recovery times and other minimally invasive benefits, but perhaps even in terms of fewer complications and quicker initiation of recommended adjuvant treatments.


References

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