Evidence - Total laparoscopic gastrectomy with D2 lymphadenectomy

  1. Literature summary

    Distal laparoscopic gastric resection and gastrectomy in gastric cancer

    In Germany, minimally invasive gastric surgery began in 1994 with the first laparoscopic BI resection and in 1996 with the first gastrectomy (1, 2). In benign gastric tumors and GIST, MIS techniques are now established standards whose widespread application is limited only by tumor size and location.

    In gastric cancer, however, the situation is different. This is because of the less complex measures needed to manage benign gastric wall processes, obviating the need for systematic lymphadenectomy or, at times, complex reconstruction of the gastric passage.

    Current study findings
    At present, there have been 9 randomized trials comparing laparoscopic and open distal gastric resection in gastric cancer (5-13) - none on gastrectomy - and 13 meta-analyses (14-26). The studies include early cancers as well as locally advanced tumors, different resection variants (distal and subtotal resection, gastrectomy), different types of lymphadenectomies (D1 and D2), and different resection techniques (BI and BII, Roux-en-Y, stapled suture, manual suture). Most of the studies are from Asia, with only one study from western countries (8).

    For distal laparoscopic gastric resection as well as laparoscopic gastrectomy in gastric cancer, the meta-analyses revealed significantly less intraoperative blood loss compared to open surgery. All meta-analyses reported significantly longer operating times for MIS procedures than for open procedures (16, 17). According to a meta-analysis from the United States, the conversion rate ranges from 0% to 6.2% (22).

    Systematic D2 lymphadenectomy (D2-LAD) of compartments I and II represents the current standard of care in gastric cancer surgery (4, 27). The oncological benefit of D2-LAD compared with the less radical D1-LAD is supported by the 2010 Dutch Gastric Cancer Study (28). According to the results of anatomic studies and the German Gastric Carcinoma Study, the computed number of lymph nodes to be resected in open procedures should be 25 (29, 30, 31). This benchmark also applies to laparoscopic lymphadenectomies. In 9 of 13 meta-analyses, open LAD resulted in a higher number of excised lymph nodes than in laparoscopic LAD, and 4 analyses yielded comparable results.

    As measured by postoperative analgesic consumption, laparoscopic gastric resections, like other MIS procedures, are significantly less painful postoperatively compared with open procedures (32). In 8 meta-analyses, hospital length of stay in laparoscopic surgery was shorter than in open resection, and 3 analyses found no difference. One analysis published in 2014 reported a reduction of about 4 days in postoperative length of stay after laparoscopic surgery (23).

    In terms of postoperative mortality, almost all analyses demonstrated benefits for MIS resections regarding wound infections (22, 32). However, not all studies found less postoperative pulmonary complications in MIS (32). Serious surgical complications such as pancreatic fistulas and suture line failures occur was similar in both surgical techniques. Nor did the meta-analyses identify any difference in the mortality rates between laparoscopic and open gastric resections.

    The long-term oncological outcomes for distal resections in early cancer and gastrectomy are the same for laparoscopic and open techniques. However, the outcomes are of limited validity because the vast majority of studies did not document long-term outcomes. The same is true for the quality of life. In a prospective randomized study from Korea on 164 patients with T1 carcinomas, patients undergoing MIS showed significant benefits within the first 3 months in terms of loss of appetite, fatigue, dysphagia, and sleep disorders (33). However, improved long-term quality of life compared with open procedures was not demonstrated (34). A Japanese study from 2014 came to the same conclusion (35).

    Conclusion: Due to the poor current data, final evaluation of minimally invasive surgery is not yet possible. Larger case series and data from the Asian region demonstrate in principle the good technical feasibility and, in oncological indications, outcomes comparable to those in open surgery.

  2. Ongoing trials on this topic

  3. References on this topic

    1: Baerlehner E (1999) Initial experience with laparoscopic gastrectomy in benign and malignant tumors. Zentralbl Chir 124:346–350
    2: Ablassmaier B, Gellert K (1996) Laparoscopic gastrectomy. A case report. Chirurg 67:643–647
    3: Meyer HJ, Hölscher AH (2012) Current S3 guidelines on surgical treatment of gastric carcinoma. Chirurg 83:31–37
    4: Moenig SP, Luebke T, Baldus SE (2005) Primärtherapie des Magenkarzinoms Ausmaß der chirurgischen Intervention. Onkologe 2005/6:630–639
    5: Cai J, Wei D (2011) A prospective randomized study comparing open versus laparoscopy-assisted D2 radical gastrectomy in advanced gastric cancer. Dig Surg 28:331–337
    6. Fujii K, Sonoda K (2003) T lymphocyte subsets and Th1/Th2 balance after laparoscopy-assisted distal gastrectomy. Surg Endosc 17:1440–1444
    7: Hayashi H, Ochiai T (2005) Prospective randomized study of open vs laparoscopy-assisted distal gastrectomy with extraperigastric lymph node dissection for early gastric cancer. Surg Endosc 19:1172–1176
    8: Huscher CG, Mingoli A (2005) Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: five-year results of a randomized prospective trial. Ann Surg 241:232–237
    9: Kim HH, Hyung WJ (2010) Morbidity and mortality of laparoscopic gastrectomy versus open gastrectomy for gastric cancer. An interim report – a phase III multicenter, prospective, randomized trial (KLASS Trial). Ann Surg 251:417–420
    10: Kim YW, Baik YH (2008) Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer: results of a prospective randomized clinical trial. Ann Surg 248:721–727
    11: Kitano S, Shiraishi N (2002) A randomized controlled trial comparing open vs laparoscopy-assisted distal gastrectomy for the treatment of early gastric cancer: an interim report. Surgery 131:S306–S311
    12: Lee JH, Han HS (2005) A prospective randomized study comparing open vs laparoscopy-assisted distal gastrectomy in early gastric cancer. Surg Endosc 19:168–173
    13: Takiguchi S, Fujiwara Y (2013) Laparoscopy-assisted distal gastrectomy versus open distal gastrectomy. A prospective randomized single-blind study. World J Surg 37:2379–2386
    14: Chen K, Xu XW (2013) Systematic review and meta-analysis of laparoscopic and open gastrectomy for advanced gastric cancer. World J Surg Oncol 11:182
    15: Chen XZ, Hu JK (2009) Short-term evaluation of laparoscopy-assisted distal gastrectomy for predictive early gastric cancer: a meta-analysis of randomized controlled trials. Surg Laparosc Endosc Percutan Tech 19:277–284
    16: Cheng Q, Pang TC (2014) Systematic review and meta-analysis of laparoscopic versus open distal gastrectomy. J Gastrointest Surg 18:1087–1099
    17: Haverkamp L, Weijs TJ (2013) Laparoscopic total gastrectomy versus open total gastrectomy for cancer: a systematic review and meta-analysis. Surg Endosc 27:1509–1520
    18: Hosono S, Arimoto Y (2006) Meta-analysis of short-term outcomes after laparoscopy-assisted distal gastrectomy. World J Gastroenterol 12:7676–7683
    19: Kodera Y, Fujiwara M (2010) Laparoscopic surgery for gastric cancer: a collective review with meta-analysis of randomized trials. J Am Coll Surg 211:677–686
    20: Memon MA, Khan S (2008) Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma. Surg Endosc 22:1781–1789
    21: Ohtani H, Tamamori Y (2011) Meta-analysis of laparoscopy-assisted and open distal gastrectomy for gastric cancer. J Surg Res 171:479–485
    22: Viñuela EF, Gonen M (2012) Laparoscopic versus open distal gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials and high-quality nonrandomized studies. Ann Surg 255:446–456
    23: Wang W, Zhang X (2014) Laparoscopic versus open total gastrectomy for gastric cancer: an updated meta-analysis. PLoS One 9:e88753
    24: Wei HB, Wei B (2011) Laparoscopic versus open gastrectomy with D2 lymph node dissection for gastric cancer: a meta-analysis. Surg Laparosc Endosc Percutan Tech 21:383–390
    25: Yakoub D, Athanasiou T (2009) Laparoscopic assisted distal gastrectomy for early gastric cancer: is it an alternative to the open approach? Surg Oncol 18:322–333
    26. Zorcolo L, Rosman AS (2011) A meta-analysis of prospective randomized trials comparing minimally invasive and open distal gastrectomy for cancer. J Surg Oncol 104:544–551
    27: Meyer HJ, Hölscher AH (2012) Current S3 guidelines on surgical treatment of gastric carcinoma. Chirurg 83:31–37
    28: Songun I, Putter H (2010) Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial. Lancet Oncol 11:439–449
    29: Siewert JR, Böttcher K (1998) Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study. Ann Surg 228:449–461
    30: Moehler M, Al-Batran SE (2011) German S3-guideline „Diagnosis and treatment of esophagogastric cancer“. Z Gastroenterol 49:461–531
    31: Wagner PK, Ramaswamy A (1991) Lymph node counts in the upper abdomen: anatomical basis for lymphadenectomy in gastric cancer. Br J Surg 78:825–827
    32: Wang W, Zhang X (2014) Laparoscopic versus open total gastrectomy for gastric cancer: an updated meta-analysis. PLoS One 9:e88753
    33: Kim YW, Baik YH (2008) Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer: results of a prospective randomized clinical trial. Ann Surg 248:721–727
    34: Kim YW, Yoon HM (2013) Long-term outcomes of laparoscopy-assisted distal gastrectomy for early gastric cancer: result of a randomized controlled trial (COACT 0301). Surg Endosc 27:4267–4276
    35: Misawa K, Fujiwara M (2014) Long-term quality of life after laparoscopic distal gastrectomy for early gastric cancer: results of a prospective multi-institutional comparative trial. Gastric Cancer.

Reviews

Aiolfi A, Sozzi A, Bonitta G, Lombardo F, Cavalli M, Campanelli G, Bonavina L, Bona D. Short-term o

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