Changing Trends in Gastric Cancer Surgery

Abstract

Gastric cancer is one of the most common causes of cancer-related death. It requires multimodal treatment and surgery is the most effective treatment modality. Radical surgery includes total or subtotal gastrectomy with lymph node dissection. The extent of lymphadenectomy still remains controversial. Eastern surgeons have performed D2 or more extended lymphadenectomy while their Western colleagues have performed more limited lymph node dissection. However, the trend has been changing in favour of D2 lymph node dissection in both hemispheres. Currently, D2 is the recommended type of lymphadenectomy in experienced centres in the west. In Japan, D2 lymph node dissection is the standard surgical approach. More extensive lymphadenectomy than D2 has not been found to be associated with improved survival and generally is not performed. Bursectomy and splenectomy are additional controversial issues in surgical performance, and trends regarding them will be discussed. The performance of bursectomy is controversial and there is no clear evidence of its clinical benefit. However, a trend toward better survival in patients with serosal invasion has been reported. Routine splenectomy as a part of lymph node dissection has largely been abandoned, although splenectomy is recommended in selected cases. Minimally invasive surgery has gained wide popularity and indications for minimally invasive procedures have been expanding due to increasing experience and improving technology. Neoadjuvant therapy has been shown to have beneficial effects and seems necessary to provide a survival benefit. Diagnostic laparoscopy should be kept in mind prior to treatment.

Keywords

• Gastric cancer, lymph node dissection, bursectomy, splenectomy, minimally invasive surgery

Kaynakça

1. 1. Yoon SS, Yang HK. Lymphadenectomy for gastric adenocarcinoma: should west meet the east? Oncologist 2009;14:871-82.
2. 2. Diggory RT, Cuschieri A. R2,3 gastrectomy for gastric carcinoma: an audited experience of a consecutive series. Br J Surg 1985;72:146-8.
3. 3. Kampschöer GH, Maruyama K, van de Velde CJ, Sasako M, Kinoshita T, Okabayashi K. Computer analysis in making preoperative decisions: a rational approach to lymph node dissection in gastric cancer patients. Br J Surg 1989;76:905-908.
4. 4. Isozaki H, Okajima K, Kawashima Y, Yamada S, Nakata E, Nishimura J, et al. Prognostic value of the number of metastatic lymph nodes in gastric cancer with radical surgery. J Surg Oncol 1993;53:247-51.
5. 5. Isozaki H, Okajima K, Fujii K, Nomura E, Izumi N, Mabuchi H, et al. Effectiveness of paraaortic lymph node dissection for advanced gastric cancer. Hepatogastroenterology 1999;46:549-54.
6. 6. Yonemura Y, Segawa M, Matsumoto H, Tsugawa K, Ninomiya I, Fonseca L, et al. Surgical results of performing R4 gastrectomy for gastric cancer located in the upper third of the stomach. Surg Today 1994;24:488-93.
7. 7. Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma. 2nd English ed. Gastric Cancer 1998;1:10-24.
8. 8. Sasako M, Sano T, Yamamoto S, Kurokawa Y, Nashimoto A, Kurita A, et al. D2 Iymphadenectomy alone or with para-aortic nodal dissection for gastric cancer. N Engl J Med 2008;359:453-62.

9. 9. Sano T, Sasako M, Yamamoto S, Nashimoto A, Kurita A, Hiratsuka M, et al. Gastric cancer surgery: morbidity and mortality results from a prospective randomized controlled trial comparing D2 and extended paraaortic lymphadenectomy--Japan Clinical Oncology Group study 9501. J Clin Oncol 2004;22:2767-73.
10. 10. Bostanci EB, Ozer I, Ercan M, Ulas M, Koc U, Karaman K, et al. A prospective observational study of 468 patients undergoing D2 or D3 lymphadenectomy for gastric cancer. Hepatogastroenterology 2013;60:624-7.
11. 11. Dent DM, Madden MV, Price SK. Randomized comparison of R1 and R2 gastrectomy for gastric carcinoma. Br J Surg 1988;75:110-2.
12. 12. Siewert JR, Böttcher K, Roder JD, Busch R, Hermanek P, Meyer HJ. Prognostic relevance of systematic lymph node dissection in gastric carcinoma. German Gastric Carcinoma Study Group. Br J Surg 1993;80:1015-8.
13. 13. Pacelli F, Doglietto GB, Bellantone R, Alfieri S, Sgadari A, Crucitti F. Extensive versus limited lymph node dissection for gastric cancer: a comparative study of 320 patients. Br J Surg 1993;80:1153-6.
14. 14. Bonenkamp JJ, Songun I, Hermans J, Sasako M, Welvaart K, Plukker JT, et al. Randomized comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet 1995;345:745-8.
15. 15. Cuschieri A, Fayers P, Fielding J, Craven J, Bancewicz J, Joypaul V, et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomized controlled surgical trial. The Surgical Cooperative Group. Lancet 1996;347:995- 9.
16. 16. Bonenkamp JJ, Hermans J, Sasako M, van de Velde CJ, Welvaart K, Songun I, et al. Extended lymph-node dissection for gastric cancer. N Engl J Med 1999;340:908-14.
17. 17. Cuschieri A, Weeden S, Fielding J, Bancewicz J, Craven J, Joypaul V, et al. Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial. Surgical Co-operative Group. Br J Cancer 1999;79:1522-30.
18. 18. Songun I, Putter H, Kranenbarg EM, Sasako M, van de Velde CJ. Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial. Lancet Oncol 2010;11:439-49.
19. 19. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 2011;14:113-23.
20. 20. Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer 2011;14:101-12.
21. 21. Sano T, Aiko T. New Japanese classifications and treatment guidelines for gastric cancer: revision concepts and major revised points. Gastric Cancer 2011;14:97-100.
22. 22. Blouhos K, Boulas KA, Hatzigeorgiadis A. Bursectomy in gastric cancer surgery: surgical technique and operative safety. Updates Surg 2013;65:95-101. 23. Hundahl SA. The potential value of bursectomy in operations for transserosal gastric adenocarcinoma Gastric Cancer 2012;15:3-4.
23. 24. Imamura H, Kurokawa Y, Kawada J, Tsujinaka T, Takiguchi S, Fujiwara Y, et al. Influence of bursectomy on operative morbidity and mortality after radical gastrectomy for gastric cancer: results of a randomized controlled trial. World J Surg 2011;35:625-30.
24. 25. Fujita J, Kurokawa Y, Sugimoto T, Miyashiro I, Iijima S, Kimura Y, et al. Survival benefit of bursectomy in patients with resectable gastric cancer: interim analysis results of a randomized controlled trial. Gastric Cancer 2012;15:42-8.
25. 26. Kochi M, Fujii M, Kanamori N, Kaiga T, Mihara Y, Funada T, et al. D2 gastrectomy with versus without bursectomy for gastric cancer. Am J Clin Oncol 2014;37:222-6.
26. 27. Herbella FA, Tineli AC, Wilson JL Jr, Del Grande JC. Gastrectomy and lymphadenectomy for gastric cancer: is the pancreas safe? J Gastrointest Surg 2008;12:1912-4.
27. 28. Eom BW, Joo J, Kim YW, Bae JM, Park KB, Lee JH, et al. Role of bursectomy for advanced gastric cancer: Result of a case control study from a large volume hospital. Eur J Surg Oncol 2013;39:1407-14.
28. 29. Yamamura Y, Ito S, Mochizuki Y, Nakanishi H, Tatematsu M, Kodera Y. Distribution of free cancer cells in the abdominal cavity suggests limitations of bursectomy as an essential component of radical surgery for gastric carcinoma. Gastric Cancer 2007;10:24-8.
29. 30. Shen WS, Xi HQ, Wei B, Chen L. Effect of gastrectomy with bursectomy on prognosis of gastric cancer: a meta-analysis. World J Gastroenterol 2014;20:14986-91.
30. 31. Hirao M, Kurokawa Y, Fujita J, Imamura H, Fujiwara Y, Kimura Y, et al. Long-term outcomes after prophylactic bursectomy in patients with resectable gastric cancer: Final analysis of a multicenter randomized controlled trial. Surgery 2015;157:1099-105.
31. 32. Yu W, Choi GS, Chung HY. Randomized clinical trial of splenectomy versus splenic preservation in patients with proximal gastric cancer. Br J Surg 2006;93:559-63.
32. 33. Kunisaki C, Makino H, Suwa H, Sato T, Takashi O, Nagano Y, et al. Impact of splenectomy in patients with gastric adenocarcinoma of the cardia. J Gastrointest Surg 2007;11:1039-44.
33. 34. Yang K, Chen XZ, Hu JK, Zhang B, Chen ZX, Chen JP. Effectiveness and safety of splenectomy for gastric carcinoma: a meta-analysis. World J Gastroenterol 2009;15:5352-9.
34. 35. Zhu GL, Sun Z, Wang ZN, Xu YY, Huang BJ, Xu Y, et al. Splenic hilar lymph node metastasis independently predicts poor survival for patients with gastric cancers in the upper and/or the middle third of the stomach. J Surg Oncol 2012;105:786-92.
35. 36. Kosuga T, Ichikawa D, Okamoto K, Komatsu S, Shiozaki A, Fujiwara H, et al. Survival benefits from splenic hilar lymph node dissection by splenectomy in gastric cancer patients: relative comparison of the benefits in subgroups of patients. Gastric Cancer 2011;14:172-7.