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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
One randomized trial
in a Western population
did demonstrate reduced