Approximately 22,000 people are diagnosed with gastric adenocarcinoma each year in the United States. Currently, surgical resection is the only potentially curative treatment for this patient group. When treating individuals with gastric cancer, the goal is to perform a successful oncologic resection safely while preserving patients’ quality of life. Some controversies exist regarding the treatment strategy and methods physicians use to perform the resection, particularly over the decision on whether or not laparoscopic gastrectomy is appropriate.
Open gastrectomy is the most commonly used surgery in patients with resectable adenocarcinoma, but a laparoscopic approach has shown efficacy as an alternative. In fact, it may even be a preferable treatment option for select patient populations. In the April 4, 2009 Annals of Surgical Oncology, my colleagues and I compared the technical feasibility and oncologic efficacy of laparoscopic gastrectomy with open subtotal gastrectomy for gastric adenocarcinoma. As one of the largest U.S. studies of laparoscopic gastrectomy to date, our investigation demonstrated that the procedure appears to be both safe and effective.
Comparing Gastrectomy Techniques
In our analysis, we studied the operative characteristics and short-term oncologic and surgical outcomes of patients who underwent laparoscopic gastrectomy as compared with those who underwent open gastrectomy. Despite a longer median operative time, the minimally invasive approach was associated with the following:
• Decreased length of hospital stay.
• Reduced need for postoperative pain relief.
• Fewer complications.
• Comparable rates of recurrence-free survival after 36 months follow-up.
Additionally, the short-term oncologic results yielded equivalent margin status and adequate lymph node retrieval. This is a critical aspect of cancer surgery—in order to stage patients appropriately and determine whether the cancer has spread, 15 or more nearby lymph nodes must be carefully removed and examined.
The potential complications of laparoscopic gastrectomy are comparable to those of open gastrectomy. However, research has shown that about 10% of patients who have an open incision for a gastrectomy develop ventral hernia; this complication often requires further surgery. The laparoscopic approach, on the other hand, reduces the risk of incisional hernia.
Patient Criteria & Physician Expertise
Laparoscopic subtotal gastrectomy for adenocarcinoma is comparable to the open approach, demonstrating equivalent margin status, adequate lymph node retrieval, technical feasibility, and equivalent short-term recurrence-free survival. Although patient selection criteria for laparoscopic gastrectomy have yet to be defined, those who have had multiple prior abdominal surgeries or who are obese may not qualify for this approach. Also, an open approach may be more appropriate for patients who have advanced disease that has invaded surrounding structures so that all of the cancer can be successfully removed. Furthermore, it should be noted that there is a significant learning curve associated with laparoscopic gastrectomy. As such, the technique should be performed on select patients in high-volume medical centers by physicians with advanced laparoscopic skills.
Surgeons in the U.S. have significantly less experience with laparoscopic gastrectomy than those in other countries, where minimally invasive gastrectomy is performed more routinely. This has been the result of the tremendous incidence of patients with gastric cancer found in different parts of the world, particularly in Asian countries. Fortunately for physicians considering this treatment strategy, data from larger studies in other counties have supported the notion that laparoscopic gastrectomy is a safe, effective, and well-accepted technique.
Readings & Resources (click to view)
Strong VE, Devaud N, Allen PJ, et al. Laparoscopic versus open subtotal gastrectomy for adenocarcinoma: a case-control study. Ann Surg Oncol. 2009;16:1507-1513.
Pugliese R, Maggioni D, Sansonna F, et al. Total and subtotal laparoscopic gastrectomy for adenocarcinoma. Surg Endosc. 2007;21:21-27.
Sarela AI. Entirely laparoscopic radical gastrectomy for adenocarcinoma: lymph node yield and resection margins. Surg Endosc. 2009;23:153-160.
Lee WJ, Wang W, Chen TC, et al. Totally laparoscopic radical BII gastrectomy for the treatment of gastric cancer: a comparison with open surgery. Surg Laparosc Endosc Percutan Tech. 2008;18:369-374.
Topal B, Leys E, Ectors N, et al. Determinants of complications and adequacy of surgical resection in laparoscopic versus open total gastrectomy for adenocarcinoma. Surg Endosc. 2008;22:980-984.