Distal Laparoscopic Gastric Resection and Gastrectomy in Gastric Cancer
Minimally invasive gastric surgery began in Germany in 1994 with the first laparoscopic B-I resection and in 1996 with the first gastrectomy (1, 2). For benign gastric tumors and GIST, MIC techniques are now established standards, whose broad application is limited only by tumor size and location.
In contrast, the situation is different for gastric cancer. This is due to the manageable, less complex procedures in benign gastric wall processes without the need for systematic lymphadenectomy or sometimes complex reconstructions of the passage.
Study Situation
Currently, there are 9 randomized studies comparing laparoscopic and open distal gastric resection in gastric cancer (5 – 13) – none, however, for gastrectomy – and 13 meta-analyses (14 – 26). The studies consider both early carcinomas and locally advanced tumors, various resection variants (distal and subtotal resection, gastrectomy), different forms of lymphadenectomy (D1 and D2), and different resection techniques (BI and BII, Y-Roux, mechanical suture, hand suture). The majority of the studies come from Asia, with only one study from the Western world (8).
For distal laparoscopic gastric resection as well as for laparoscopic gastrectomy, the meta-analyses show a significantly lower intraoperative blood loss compared to open surgery in gastric cancer. The duration of the procedure is significantly longer for MIC procedures than for open procedures in all meta-analyses (16, 17). According to a meta-analysis from the USA, the conversion rate is between 0 and 6.2% (22).
The systematic D2 lymphadenectomy (D2-LAD) of compartments I and II represents the current standard in gastric cancer surgery (4, 27). The oncological advantage of D2-LAD compared to the less radical D1-LAD is demonstrated by the Dutch gastric cancer study from 2010 (28). According to the results of anatomical studies and the German gastric cancer study, the number of lymph nodes to be removed should include 25 lymph nodes in open procedures (29, 30, 31). This guideline also applies to laparoscopic lymphadenectomies. In 9 out of 13 meta-analyses, open LAD resulted in a higher number of removed lymph nodes than laparoscopic LAD, 4 analyses showed comparable results.
Measured by postoperative analgesic consumption, as with other MIC procedures, postoperative pain in laparoscopic gastric resections is significantly lower compared to open procedures (32). In 8 meta-analyses, the hospital stay after laparoscopic procedures is shorter compared to open resection, 3 analyses show no difference. A 2014 analysis reports a postoperative stay shortened by about 4 days after laparoscopic technique (23).
Regarding postoperative mortality, almost all analyses show advantages for MIC resections in terms of wound infections (22, 32). A reduction in pulmonary postoperative complications cannot be found for MIC procedures in all studies (32). Serious surgical complications such as pancreatic fistulas and anastomotic insufficiencies occur equally frequently in both surgical procedures. Also, for lethality, the meta-analyses show no difference between laparoscopic and open gastric resections.
The oncological long-term results for distal resections in early carcinomas and gastrectomies are the same for laparoscopic and open techniques. However, the results are only conditionally valid, as in the majority of studies the long-term results were not recorded. The same applies to quality of life. In a prospective randomized study from Korea, which included 164 patients with T1 carcinomas, patients who were operated on using MIC technique showed significant advantages in terms of loss of appetite, fatigue, dysphagia, and sleep disturbances within the first 3 months (33). However, improved long-term quality of life compared to open procedures could not be demonstrated (34). A Japanese study from 2014 came to the same conclusion (35).
Conclusion: Due to the currently poor data situation, a final classification of the minimally invasive technique is not yet possible. Larger individual series and data from the Asian region show the principle good technical feasibility and in oncological indications results that are comparable to those of the open technique.