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Hand-assisted laparoscopic gastrectomy for cancer: The next last frontier
EDITORIAL
Hand-Assisted Laparoscopic Gastrectomy for Cancer: The Next Last Frontier John G Hunter, MD, FACS, Portland, OR “tour-de-force” similar to laparoscopic Whipple and the demonstration that we could indeed put a man on the moon. Knowing that the most complex gastrectomy can be done with minimally invasive surgery (MIS) techniques will firmly establish the role of the simpler laparoscopic techniques used for early gastric cancer. A previous editorial on this topic would have contained a discourse about the danger of treating cancer laparoscopically. Although all the answers aren’t in, clinical trials of MIS treatment of curable gastrointestinal cancer have demonstrated that laparoscopy does not promote cancer dissemination if the safety principles of open cancer surgery are applied. The most relevant questions to be answered with rigorous clinical trials are: Stage for stage, is MIS gastrectomy for cancer better than conventional gastrectomy? Will MIS gastrectomy provide quicker recovery, shorter hospitalization, and quicker return to work than conventional gastrectomy? Can MIS techniques provide these benefits without increased risk of cancer, recurrence, or cancer-related mortality? Perhaps, as one recent randomized clinical trial of MIS versus open colectomy for cancer showed, MIS gastrectomy may confer improved survival.5 Until controlled clinical trials are performed, we can only conclude that MIS gastrectomy can be done for all stages of gastric cancer. On to the next last frontier.
Surgical history is rife with declarations that “it has all been done, there is no place to go from here.” With the article published in this month’s Journal of the American College of Surgeons, it would appear that minimally invasive extended radical gastrectomy has now been successfully conquered with techniques by Uyama and colleagues from the Fujita Health University in Aichi, Japan.1 Minimally invasive surgery of the esophagus, from fundoplication to esophagectomy, has been developed and perfected in populations of European descent, but nearly all credit for the development of minimally invasive surgery of the stomach belongs to Asia, and the art has been no better perfected than in Japan. In 1991, Kitano and Shiraishi2 performed the first laparoscopic-assisted distal gastrectomy for early gastric cancer. After that, laparoscopic gastric wedge resection and intragastric mucosal resection were described by Ohgami and colleagues3 and Ohashi, respectively.4 These three techniques are widely used in Japan for treatment of early gastric cancer that cannot be managed with flexible endoscopic methods (using a mucosal lift technique), yet show no evidence of invasion deep to the mucosa. In a recent review of the subject by Kitano and Shiraishi,2 more than 4,000 such procedures were reviewed. Although these large numbers still represent the minority (20% to 30%) treatment of early gastric cancer in Japan, this represents significant penetration of the field by laparoscopy. This utilization rate exceeds that of laparoscopic hernia in the US and is about on a par with laparoscopic appendectomy. Clearly, most “advanced” laparoscopic surgeons in Japan are using these techniques to manage early gastric cancer. Now here comes the extension of these techniques to the more advanced gastric cancers, one in which the stage of the disease necessitates resection of adjacent organs, including the spleen and pancreas. Laparoscopic D3 dissection is described and is clearly “doable” by these skilled surgeons. The data in this article suggest that there is indeed a benefit to the patient when minimally invasive techniques are used. Although it is conceivable that hand-assisted laparoscopic radical gastrectomy will become the next “gold standard,” my best guess is that it will be viewed in 10 years as a
© 2004 by the American College of Surgeons Published by Elsevier Inc.
REFERENCES 1. Uyama I, Sugioka A, Sakurai Y, et al. Hand-assisted laparoscopic function-preserving and radical gastrectomies for advanced-stage proximal gastric cancer. J Am Coll Surg 2004;199:508–515. 2. Kitano S, Shiraishi N. Current status of laparoscopic gastrectomy for cancer in Japan. Surg Endosc 2004;18:182–185. 3. Ohgami M, Otani Y, Kumai K, et al. Curative laparoscopic surgery for early gastric cancer: five years experience. World J Surg 1999;23:187–192. 4. Ohashi S. Laparoscopic intraluminal (intragastric) surgery for early gastric cancer. Surg Endosc 1995;9:169–171. 5. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopyassisted colectomy versus open colectomy for treatment of nonmetastatic colon cancer: a randomized trial. Lancet 2002;359:2224– 2229.
436
ISSN 1072-7515/04/$30.00 doi:10.1016/j.jamcollsurg.2004.05.256
Hand-Assisted Laparoscopic Gastrectomy for Cancer: The Next Last Frontier John G Hunter, MD, FACS, Portland, OR “tour-de-force” similar to laparoscopic Whipple and the demonstration that we could indeed put a man on the moon. Knowing that the most complex gastrectomy can be done with minimally invasive surgery (MIS) techniques will firmly establish the role of the simpler laparoscopic techniques used for early gastric cancer. A previous editorial on this topic would have contained a discourse about the danger of treating cancer laparoscopically. Although all the answers aren’t in, clinical trials of MIS treatment of curable gastrointestinal cancer have demonstrated that laparoscopy does not promote cancer dissemination if the safety principles of open cancer surgery are applied. The most relevant questions to be answered with rigorous clinical trials are: Stage for stage, is MIS gastrectomy for cancer better than conventional gastrectomy? Will MIS gastrectomy provide quicker recovery, shorter hospitalization, and quicker return to work than conventional gastrectomy? Can MIS techniques provide these benefits without increased risk of cancer, recurrence, or cancer-related mortality? Perhaps, as one recent randomized clinical trial of MIS versus open colectomy for cancer showed, MIS gastrectomy may confer improved survival.5 Until controlled clinical trials are performed, we can only conclude that MIS gastrectomy can be done for all stages of gastric cancer. On to the next last frontier.
Surgical history is rife with declarations that “it has all been done, there is no place to go from here.” With the article published in this month’s Journal of the American College of Surgeons, it would appear that minimally invasive extended radical gastrectomy has now been successfully conquered with techniques by Uyama and colleagues from the Fujita Health University in Aichi, Japan.1 Minimally invasive surgery of the esophagus, from fundoplication to esophagectomy, has been developed and perfected in populations of European descent, but nearly all credit for the development of minimally invasive surgery of the stomach belongs to Asia, and the art has been no better perfected than in Japan. In 1991, Kitano and Shiraishi2 performed the first laparoscopic-assisted distal gastrectomy for early gastric cancer. After that, laparoscopic gastric wedge resection and intragastric mucosal resection were described by Ohgami and colleagues3 and Ohashi, respectively.4 These three techniques are widely used in Japan for treatment of early gastric cancer that cannot be managed with flexible endoscopic methods (using a mucosal lift technique), yet show no evidence of invasion deep to the mucosa. In a recent review of the subject by Kitano and Shiraishi,2 more than 4,000 such procedures were reviewed. Although these large numbers still represent the minority (20% to 30%) treatment of early gastric cancer in Japan, this represents significant penetration of the field by laparoscopy. This utilization rate exceeds that of laparoscopic hernia in the US and is about on a par with laparoscopic appendectomy. Clearly, most “advanced” laparoscopic surgeons in Japan are using these techniques to manage early gastric cancer. Now here comes the extension of these techniques to the more advanced gastric cancers, one in which the stage of the disease necessitates resection of adjacent organs, including the spleen and pancreas. Laparoscopic D3 dissection is described and is clearly “doable” by these skilled surgeons. The data in this article suggest that there is indeed a benefit to the patient when minimally invasive techniques are used. Although it is conceivable that hand-assisted laparoscopic radical gastrectomy will become the next “gold standard,” my best guess is that it will be viewed in 10 years as a
© 2004 by the American College of Surgeons Published by Elsevier Inc.
REFERENCES 1. Uyama I, Sugioka A, Sakurai Y, et al. Hand-assisted laparoscopic function-preserving and radical gastrectomies for advanced-stage proximal gastric cancer. J Am Coll Surg 2004;199:508–515. 2. Kitano S, Shiraishi N. Current status of laparoscopic gastrectomy for cancer in Japan. Surg Endosc 2004;18:182–185. 3. Ohgami M, Otani Y, Kumai K, et al. Curative laparoscopic surgery for early gastric cancer: five years experience. World J Surg 1999;23:187–192. 4. Ohashi S. Laparoscopic intraluminal (intragastric) surgery for early gastric cancer. Surg Endosc 1995;9:169–171. 5. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopyassisted colectomy versus open colectomy for treatment of nonmetastatic colon cancer: a randomized trial. Lancet 2002;359:2224– 2229.
436
ISSN 1072-7515/04/$30.00 doi:10.1016/j.jamcollsurg.2004.05.256