ACS Bulletin - July 2017

68 |

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

by Matthew S. Strand, MD; Vivian E. Strong, MD, FACS;

Ryan C. Fields, MD, FACS; and Judy C. Boughey, MD, FACS

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