The role of laparoscopic surgery in gastric cancer.

The laparoscopic surgery in gastric cancer is applied with increasing frequency nowadays; noticeable reports come mainly from Korea and Japan with satisfactory results. This review presents briefly the issue by evaluating its role. A PubMed search of relevant articles published up to 2010 was performed to identify current information. Most data come from Far East, where gastric cancer occurs more often, and the proportion of early gastric cancer is high. Laparoscopic approach includes both the diagnostic laparoscopy and laparoscopic resection. Laparoscopic gastrectomy has currently limited application for gastric cancer in the West; it is not widely accepted and raises important considerations necessitating the planning of multicentre randomised control trials based mainly on the long-term results.

INTRODUCTION

Laparoscopic gastrectomy is safe and effective in specialised centres.[1-5] Recently, a number of noticeable reports come from Korea and Japan on laparoscopic surgery in gastric cancer with satisfactory results.[6-9] The laparoscopic approach in the management of gastric cancer is applied with increasing frequency nowadays, as well as in other intra-abdominal malignancies, particularly in cancer of the colon. However, most data come from Japan and South East Asia, where gastric cancer occurs more often, and the proportion of early gastric cancer is high.[6-19]

The question that can be arisen is whether the cancer of the stomach in the West is a different disease than that in the East. It is certainly clear that there is more experience there, since the incidence is greater than six times; it was estimated in the European Union in 2004 at 12.4 per 1,00,000 inhabitants per year. The different results perhaps could be attributed to the higher rate of both location in the upper stomach and diffuse type microscopically in the West, in which total gastrectomy is necessary, but with twice mortality than subtotal gastrectomy. It appears that the disease is probably the same in terms of biological behaviour, but the patients are different. Patients with gastric cancer in the West, compared to those in Far East, are 10 years older, have a higher proportion of concomitant cardiovascular disease, are more overweight and in higher risk of thromboembolic complications. It is well-known that obesity interferes with the lymph node dissection.[20]

The progress led to the innovation of appropriate stapler devices and contemporary energy sources making possible the laparoscopic approach. The first laparoscopic gastrectomy with Billroth II reconstruction was carried out by Goh et al. in 1992, while the first laparoscopic gastrectomy for cancer by Azagra et al. in 1993.[21] The laparoscopic approach in gastric cancer includes both the diagnostic laparoscopy and laparoscopic resection.

DIAGNOSTIC LAPAROSCOPY

The diagnostic laparoscopy for staging of gastric cancer ensures the avoidance of unnecessary laparotomy in one-third of the cases, given that in these patients exists intra-abdominal disease stage M1 (metastases to peritoneum, liver or non-local lymph nodes) that cannot be detected radiographically by modern imaging techniques.[22-25] The routine application in any case is not the appropriate policy and has been abandoned, because a significant proportion of patients underwent an undue intervention that increases the risk of complication and financial cost. Its selective performance based on specific indications is currently the method of choice. These indications include the locally advanced tumour by endoscopic or radiological evaluation (stage ≥ T2), radiological disease stage M0, patient by view of general condition suitable candidate for gastrectomy as well as no need to deal with gastric outlet obstruction or bleeding.[23]

It is limited, nowadays, to patients with high probability for disease stage M1, although it may be substituted largely by high-definition computed tomography (spiral CT). Moreover, it may be omitted when the diameter of lymph nodes in CT is ≤1 cm and there is no infiltrating involvement of the gastroesophageal junction or the whole stomach.[26]

Laparoscopic diagnostic peritoneal lavage cytology has been used in staging of locally advanced gastric cancer avoiding unnecessary gastrectomies. Positive peritoneal cytology is a marker of poor prognosis even in the absence of overt peritoneal metastases. It is a safe and effective new modality, especially in patients receiving neoadjuvant chemotherapy.[2728]

LAPAROSCOPIC GASTRECTOMY

The laparoscopic resection of gastric cancer is based on the advantages of laparoscopic surgery for gastrointestinal cancer, which generally include milder postoperative course, better respiratory function and increased immune response.

The minimally invasive surgery was initially restricted to early gastric cancer (EGC). Endoscopic mucosal resection is applied to cancer confined to the mucosa or submucosa; it is intestinal type microscopically, without ulceration and with a diameter <2 cm. The laparoscopic approach to early gastric cancer includes the wedge excision, the intragastric mucosal resection and D1 gastrectomy (clearance of local lymph nodes). The latter is performed either as a whole laparoscopic or laparoscopic assisted manually or as an open assisted by laparoscopy.[29-32] Hybrid natural orifice transluminal endoscopic surgery has been performed recently in patients, with EGC ensuring endoscopic resection and laparoscopic lymph node dissection.[33]

Laparoscopic-assisted distal gastrectomy (LADG) has been proved superior to open distal gastrectomy (ODG) for early gastric cancer.[34]

The laparoscopic approach, with the achieved progress and gained experience, can be applied in all cases, even in advanced gastric cancer; in this case, laparoscopic D2 gastrectomy is performed. It includes additional clearance of lymph nodes along the main branches of the celiac artery.[35] This gastrectomy, according to the location of the tumour, may be distal, proximal or total with oesophagojejunal anastomosis.[3637] As it has been proved, both Billroth I and Billroth II ensure safe reconstruction after LADG.[6]

Recently, indocyanine green fluorescence imaging has been proposed for laparoscopic detection of sentinel lymph node, avoiding unnecessary extended resection.[38]

RESULTS

The short-term results of laparoscopic gastrectomy compared with open surgery show longer operating time, which is influenced by the experience of surgeon, however, less blood loss, the same or lower rate of postoperative complications, morbidity about 10%, faster recovery of bowel function, less postoperative pain, shorter hospitalisation and convalescence period and better lung function due to the less pain.[303940]

Recently, a meta-analysis of five randomised clinical trials showed that LADG was significantly superior to ODG regarding the volume of blood loss (108.57 ml lesser), duration of hospital stay, level of pain and risk of complications. There was no difference in the resumption of oral intake, rate of tumour recurrence and mortality. However, LADG was significantly inferior to ODG regarding operative time (96.47 minutes greater) and had also a smaller number of harvested lymph nodes (4.88 lymph nodes lesser).[41]

Short-term outcome by times in more detail regarding number of patients, length of operation and blood loss is shown in Table 1.

Table 1

Laparoscopic gastrectomy. Statistics for short-term outcome of several series by time

In a recent report of a Western centre experience, laparoscopy-assisted gastectomy (LAG) with extended lymphadenectomy for gastric cancer is feasible and safe, gaining advantages despite the higher morbidity; also, it can achieve a radical oncologic outcome.[42]

The long-term results and 5-year survival of laparoscopic D2 subtotal gastrectomy are acceptable.[43]

Laparoscopy-assisted resection for gastric stump cancer is technically feasible, nowadays.[44] The safety of laparoscopic subtotal gastrectomy for gastric cancer in the elderly has been proved.[45] Robotic gastrectomy is feasible, nowadays.[46]

The long-term outcome of laparoscopic gastrectomy for cancer is still based on limited data, which show similar with open gastrectomy morbidity and mortality, five-year survival and disease-free survival as well as lower overall financial cost.[36]

There have been few reports for long-term survival. A cumulative 5-year survival up to 98.4% for LADG for early gastric cancer has been reported.[29] Actuarial 5-year survival after R0 laparoscopic gastrectomy for advanced gastric cancer reached up to 34%.[47] A recurrence rate of 24% have been reported for advanced gastric cancer after total and subtotal laparoscopic gastrectomy with extended lymph node dissection; 3-year overall and disease-free survival rates were 75%.[36] A median survival of 30 months for both open and laparoscopic gastrectomy has recently been reported in a large number of 398 patients who underwent radical gastrectomy (R0) for gastric cancer.[7] Also, an overall 5-year survival of 97% for early gastric cancer and 67% for advanced gastric cancer after D2 subtotal gastrectomy by minimally invasive surgery has been reported.[43]

The disadvantages of laparoscopic gastrectomy for cancer include appropriate training in advanced laparoscopic surgery, with a learning period of 50 cases required[48] and the putative effect of pneumoperitoneum on the growth, proliferation and spread of cancer cells. The latter can lead to a possible dissemination that can be either intraperitoneal or haematogenous as well as in the port sites of trocars.[39]

CONCLUSIONS

It seems that the laparoscopic approach in gastric cancer has currently limited application in the West; it is not widely accepted and raises important considerations necessitating the planning of multicentre randomised control trials based mainly on the long-term results.