Review: Minimally Invasive Surgery for Gastric Cancer
Key findings
- A growing body of evidence demonstrates the safety and feasibility of minimally invasive gastrectomy and its oncologic equivalency to open gastrectomy
- For treatment of early gastric cancer, studies of laparoscopic gastrectomy from Western countries, including a randomized trial, have had outcomes similar to those published in studies from Eastern countries
- Although operative time is increased with laparoscopic gastrectomy for advanced gastric cancer, its outcomes are similar to those of open surgery, including lymph node yields, recurrence and overall survival
- The decreased morbidity and faster recovery associated with the minimally invasive approach increases the likelihood that patients will receive timely adjuvant therapy
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Minimally invasive techniques for treatment of gastric cancer have been steadily adopted worldwide since 1994 when the first laparoscopic-assisted gastrectomy was performed. A growing body of data suggests that laparoscopic and robotic gastrectomy may be preferred treatments for gastric cancer in well-selected patient populations.
In a review written for Surgical Oncology Clinics of North America, Christina L. Costantino, MD, clinical fellow in the Department of Surgery, and John T. Mullen, MD, director of the General Surgery Residency Program and a clinician in the Massachusetts General Hospital Cancer Center—who performs almost exclusively traditional, open gastrectomies—dissect this evidence and explain what to consider when stratifying individual patients to the most appropriate surgical technique.
Laparoscopic Gastrectomy for Early Gastric Cancer
Most surgeons in Asian countries now use laparoscopic gastrectomy for clinical T1N0 disease that is not endoscopically resectable. The most recent prospective, randomized trials show that minimally invasive gastrectomy is oncologically equivalent to open gastrectomy.
These trials also show that laparoscopic gastrectomy requires increased operative time compared with open procedures. However, it is at least equivalent, if not superior, in outcomes such as length of stay, postoperative pain and intraoperative blood loss.
The decreased morbidity and faster recovery increase the likelihood that patients will receive timely adjuvant therapy.
Western countries have been slower to adopt laparoscopic gastrectomy, presumably because the incidence of gastric cancer is markedly lower than in the East. Because of the potential benefits, though, the technique is gaining popularity. Several nonrandomized studies from Western centers have found that laparoscopic gastrectomy is safe and effective for well-selected patients with early gastric cancer.
In the only prospective, randomized trial conducted in the West, operative mortality and morbidity rates were not significantly different from those for open procedures. Further, there was no difference between groups in five-year-overall or disease-free survival.
Laparoscopic Gastrectomy for Advanced Gastric Cancer
Laparoscopic surgery for advanced gastric cancer is even more technically challenging because of the complexities of lymph node dissection and resection of bulky, locally advanced tumors. Even so, several centers in Asia have published nonrandomized studies that demonstrate its safety and oncologic efficacy.
Multiple meta-analyses have concluded that laparoscopic and open gastrectomy have similar outcomes in advanced gastric cancer, including similar lymph node yields and equivalent recurrence and overall survival.
In the most comprehensive and stringent of these meta-analyses, laparoscopic distal gastrectomy was associated with a longer operative time, but also lower complication rates, less blood loss and shorter hospital stay.
The potential survival advantage lymph node dissection for patients with gastric cancer is a matter of great debate, partly because few long-term data are available.
Robotic Gastrectomy for Gastric Cancer
Based on two meta-analyses published in 2017, the reviewers consider robotic gastrectomy with extended lymphadenectomy to be safe and to have short-term oncologic outcomes (R0 resection rate and nodal yield) equivalent to those of laparoscopic and open gastrectomy. Existing data are inadequate to compare robotic gastrectomy to other approaches in terms of survival.
Choice of Approach
Patients in Eastern countries tend to present with gastric cancer at a younger age than in the West, and they generally have lower body mass index and fewer medical comorbidities. These are major influences on the choice between open and minimally invasive gastrectomy.
Other considerations include:
- Results of endoscopic ultrasound and cross-sectional imaging with a high-quality, multiphasic computed tomography scan
- Vascular anomalies, which should be examined through arterial phase imaging
- Planned method of gastrointestinal reconstruction and whether it will be done intracorporeally or extracorporeally
- Surgeon experience. The learning curve for minimally invasive distal gastrectomy has been estimated at approximately 60 to 90 cases, a daunting number for Western surgeons given the low number of cases. For minimally invasive total gastrectomy, that figure may be closer to 100 cases
- For surgeons who already have advanced laparoscopic skills, the learning curve may be far less steep
- Robotic gastric surgery may be easiest of all because of three-dimensional imaging and articulating instruments
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