By Vivian E. Strong, MD, FACS; and Ryan C. Fields, MD, FACS
- Minimally invasive gastrectomy is standard of care in Asia where patients often present with early-stage disease.
- Several retrospective studies have suggested that laparoscopic-assisted gastrectomy is associated with less blood loss, decreased hospital stay, less pain, decreased early postoperative complications, and comparable survival compared to open gastrectomy.
- Patient selection is critical for achieving acceptable outcomes with minimally invasive gastrectomy. Considerations include size and location of the tumor, prior abdominal surgery, patient body habitus, and surgeon experience.
Gastric cancer is a significant problem worldwide. In 2016, there were an estimated 26,370 new cases and 10,730 deaths from gastric cancer in the United States.1 The incidence is rising, particularly with respect to proximal tumors, and among whites under age 40, with a nearly 70% increase in incidence over the past few years.2 In addition, more early-stage gastric cancers are being identified, allowing for more minimally invasive surgical approaches.
Minimally invasive surgery refers to both laparoscopic- and robotic-assisted cases. Clear advantages of minimally invasive surgery have been demonstrated for some operations, such as cholecystectomy and colectomy, including decreased postoperative pain, morbidity, recovery time, length of hospital stay, and overall hospital cost.3 For other operations, such as appendectomy and hernia repair (both ventral/incisional and inguinal), the benefits are less clear.
Compared with surgery for benign conditions, surgery for malignancy has additional factors to consider when discussing differences between open and minimally invasive surgery. Of utmost importance is the oncologic outcome. If a minimally invasive approach led to an unacceptable oncologic outcome, it should clearly not be performed. This may include well-established quality metrics, such as surgical margins and lymph node counts. In rectal cancer, for example, results from the ACOSOG Z6051 study demonstrated that the use of laparoscopic resection failed to meet criteria for noninferiority for pathologic outcomes. The study authors concluded that laparoscopic resection should not be used for these patients.4
For the multimodality care of patients with gastric cancer, is there a role for the minimally invasive approach? Theoretical advantages are shorter length of hospital stay, fewer complications (especially wound/incision-related), and possible earlier return to intended adjuvant therapy. Minimally invasive surgery may be beneficial if these advantages could be achieved with equivalent oncologic outcomes and without an unacceptable increase in cost. Minimally invasive gastrectomy has become standard of care in Asia, which has some of the highest gastric cancer incidence rates in the world.5 Many Asian countries have employed screening programs, allowing for the disease to be diagnosed at early stages when a minimally invasive surgical approach is most effective. Data are less robust in Western populations, where patients typically present with more advanced disease and studies on minimally invasive surgery are fewer.
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, pain scores, and length of hospital stay; improved quality of life; and longer operative times.6-8 Notably, these studies predominantly comprise patients with small, distal tumors identified during routine-screening endoscopy.
The Korean Laparoendoscopic Gastrointestinal Surgery Study group is a multicenter effort to evaluate the oncologic feasibility of LADG versus open distal gastrectomy for early-stage gastric cancer. Initial results showed a decrease in overall complication rate in the laparoscopic group (13.0% vs. 19.9%, p = 0.001).8 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, lymph node in the LADG group was slightly inferior to open gastrectomy (40.5 vs. 43.7, p < 0.001), but was nonetheless sufficient for pathologic staging.8
Meta-analyses of LADG for early gastric cancer have 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, decreased length of hospital stay,9 significantly fewer complications, and equivalent oncologic outcome.10
One randomized trial in a Western population did demonstrate reduced intraoperative blood loss, earlier resumption of oral intake, and a shorter length of hospital stay for patients that underwent laparoscopic compared with open radical subtotal gastrectomy, with no differences in long-term oncologic outcome.6 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 cancer were able to undergo treatment after laparoscopic gastrectomy compared with open, perhaps suggesting another benefit for minimally invasive approaches in terms of quicker and more complete recovery.11
Advanced Gastric Cancer and Total Gastrectomy
Initial results supporting the use of minimally invasive gastrectomy for early-stage gastric cancer have led to its increasing use in the treatment of advanced gastric cancer. Several retrospective studies have suggested that laparoscopic-assisted gastrectomy is associated with less blood loss, decreased hospital stay, less pain,12 decreased early postoperative complications,13 and no difference in overall survival compared to open gastrectomy.12,14 One randomized trial has compared laparoscopic-assisted gastrectomy with open gastrectomy.15 Although operative duration was longer in the laparoscopic group, pulmonary infection was more frequent in the open group. There was no difference in morbidity or mortality.
Meta-analyses of laparoscopic-assisted gastrectomy for advanced gastric cancer have demonstrated longer procedure times, decreased intraoperative blood loss, decreased length of hospital stay, similar number of lymph nodes harvested,16 and decreased complications,10 as well as no difference in overall or disease-free survival between laparoscopic-assisted gastrectomy and open gastrectomy.17
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 up to 90 cases may be required for proficiency.18 For total gastrectomies, as many as 100 cases may be needed.19 Importantly, most of the highest-volume surgeons are from Asia, where gastric cancer care is centralized at a small number of hospitals, allowing surgeons to dedicate their practice to these technically challenging operations.
There are multiple ongoing randomized trials evaluating the efficacy of laparoscopic gastrectomy, both for early cancers and for advanced disease (Table).
A high-quality oncologic operation should always take precedence over surgical approach (open vs. laparoscopic). However, as surgical experience with minimally invasive techniques grows and as technology advances, there is clearly an important role for minimally invasive resections for well-selected patients with gastric cancer. The indications for this approach continue to advance and may provide benefits for our patients—not only in faster recovery time and in other minimally invasive benefits—but also, perhaps, in terms of fewer complications and quicker initiation of needed adjuvant treatments. Although the learning curve for minimally invasive gastrectomy is high, it can be achieved in high-volume centers with appropriate mentorship and training. More advanced laparoscopic equipment and robotic approaches may make the learning curve less steep and allow these surgical techniques to become more widespread. The absolute benefit will continue to be defined by the ongoing clinical trials addressing this topic.
About the Authors: Dr. Strong is in the Department of Surgery at Memorial Sloan Kettering Cancer Center. Dr. Fields is in the Department of Surgery at Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine in St. Louis.