metricas
covid
Buscar en
Cirugía Española (English Edition)
Toda la web
Inicio Cirugía Española (English Edition) Current Status of Gastrectomy for Cancer: “Less Is Often More”
Journal Information
Vol. 96. Issue 10.
Pages 603-605 (December 2018)
Vol. 96. Issue 10.
Pages 603-605 (December 2018)
Editorial
Full text access
Current Status of Gastrectomy for Cancer: “Less Is Often More”
Estado actual de la gastrectomía por cáncer. «Less is often more»
Visits
3746
Juan S. Azagraa, Aingeru Sarriugartea,b,
Corresponding author
, Francisco Javier Ibañeza,c
a Department of Visceral and Mini-Invasive Surgery, Centre Hospitalier de Luxembourg, Luxembourg
b Departamento de Cirugía, OSI-EE Cruces, BioCruces, Universidad del País Vasco UPV/EHU, Barakaldo, Bizkaia, Spain
c Departamento de Cirugía, OSI Hospital de Galdakao-Usansolo, Galdácano, Bizkaia, Spain
This item has received
Article information
Full Text
Bibliography
Download PDF
Statistics
Full Text

Gastric cancer is currently the third leading cause of cancer mortality worldwide. Despite advances in treatment, it continues to present an unfavorable prognosis, with a 5-year survival of around 25%.1 Thanks to better food preservation, the incidence has declined in recent decades in developed countries. However, more proximal and diffuse tumor infiltration are on the rise, occurring in younger patients. At present, gastric cancer remains a disease that is managed surgically, and the surgeon should direct the treatment with curative intent, from diagnosis to follow-up. Even today, the majority of patients with gastric cancer worldwide continue to be operated on straight away, with no prior assessment for combined treatment. However, the treatment of gastric cancer should now follow a multidisciplinary approach, as better survival has been demonstrated in patients treated with either associated perioperative chemotherapy or postoperative radio-chemotherapy.2 In order to adequately select patients and plan for their treatment, all patients with gastric cancer should be evaluated by a committee of specialists from the different disciplines involved in the therapeutic process. Our patients receive neoadjuvant chemotherapy at preoperative stages above T2N+ and undergo surgery 4 weeks later. Postoperative radio-chemotherapy is maintained in patients who have not received prior neoadjuvant chemotherapy, patients with unsatisfactory resections (R1) or those with factors for a poor prognosis in the pathology study.3 Furthermore, in order to reduce preoperative complications, enteral immunonutrition should be considered, especially in patients with different degrees of malnutrition.4

Worldwide, open surgery is still the preferred approach for gastrectomy due to cancer.5 However, the technical development of laparoscopy and the experience accumulated over the years through bariatric surgery have led to more and more hospitals performing laparoscopic gastrectomies for cancer. Once the learning curve is overcome, several current series have proven not only the safety and reproducibility of mini-invasive techniques, but also a lower rate of complications and hospital stay, all without compromising the oncologic prognosis.6 Our group performed the first total gastrectomy for cancer in 1996, which was the first oncological resection in gastric cancer performed in the West and the first total gastrectomy in the world.7 Since then, we have been progressively developing the technique and extending the indication of its use to perform practically all gastrectomies in this manner today, with a conversion rate that is nearly zero. Currently, there are no absolute contraindications for laparoscopic gastrectomy at advanced medical centers, although previous interventions or certain patient comorbidities may make the open approach recommendable.8

There is controversy regarding the magnitude of gastric resection that should be performed according to the location of the tumor. International clinical guidelines recommend total gastrectomy for cases in which the tumor presents proximally and for those with diffuse infiltration with the aim of achieving a proximal safety margin of 5–8cm.9–11 However, even in experienced hands, total gastrectomy presents significantly higher morbidity and mortality than subtotal gastrectomy. The most feared of the complications is esophagojejunal anastomotic leak, which entails high morbidity and mortality that can lead to death in a significant number of patients. In this regard, we believe that extended gastric resections, such as the 95% gastrectomy previously standardized by our group,12 which may or may not be associated with intraoperative biopsy by freezing the surgical margins, can even help achieve R0 resection of tumors in the body and fundus of the stomach without the need to systematically perform total gastrectomies, thus significantly reducing morbidity and mortality.13

Traditionally, en bloc omentectomy with the gastric resection piece has been considered necessary in oncological gastrectomy to treat cancer. However, the expansion of video-assisted oncological gastrectomies has raised some controversies about this need and the way to conduct omentectomy itself. Even in open surgery, especially in patients with previous interventions, omentectomy is not always simple and can be associated with complications, such as injuries to the spleen or transverse mesocolon, as previously described by other authors.14 Furthermore, the literature reports finding lymph nodes in only a small percentage of total omentectomy pieces (0%–28%). This may possibly be related to the lymph node group4 resected with the greater omentum, which presents in advanced disease stages metastasis in 2% of cases and peritoneal implants in 3%–8%.15,16 According to other published cohort studies, no differences have been observed between the disease-free period and 3-year and 5-year survival between patients with total and partial omentectomy.14–16 Currently, the European (ESMO) and American (NCCN) guidelines on gastric cancer do not mention omentectomy as part of the treatment for gastric cancer, while the Japanese Gastric Cancer Treatment Guidelines recommend complete omentectomy for T3–T4 tumors.9–11 Moreover, in reviewing the surgical literature, we found that there is no prospective randomized study demonstrating the need to associate omentectomy in a radical gastrectomy.17 Therefore, in our opinion, total omentectomy is not necessary in oncological gastrectomy, so we perform partial omentectomy, initiating the resection 4cm distal to the gastroepiploic vessels.

Bursectomy, or resection of the peritoneum of the lesser sac, is only recommended for T3–T4 tumors with serous positivity on the posterior side of the stomach. Its aim is to eliminate possible microscopic peritoneal implants, so it should not be performed routinely in gastrectomies for cancer. Along this same line, a treatment that seems to be beneficial is Hyperthermic Intra Peritoneal Chemotherapy (HIPEC), which is performed by mini-invasive techniques in gastric tumors with microscopic peritoneal disease. Nevertheless, for the time being it cannot be considered a standard treatment and should be reserved for specialized medical centers.18,19

Another of the continuing points of debate that has aroused interest in recent years is the extension of lymph node dissection. There is sufficient evidence to support that D2 lymphadenectomy decreases the recurrence rate and increases survival compared to D1.20 Furthermore, the preservation of lymph node groups 10 and 11d seems to be related with a decrease in complications, which is why our group routinely performs en bloc extraction of lymph node groups 1–6 added to 7, 8, 9, 11p and 12, resecting stations 10 and 11d only in cases in which the tumor is located in the upper part of the greater curvature or presents extension toward the gastrosplenic ligament and short vessels.21

The expansion of mini-invasive techniques has led to the generalization of multimodal rehabilitation measures in gastric surgery, which implies a better and faster recovery of patients with a shorter hospital stay and a greater degree of satisfaction. None of the patients treated surgically by our group was systematically admitted to the intensive care unit, had central venous catheters, nasogastric or urinary catheters or surgical drainage, and oral intake and mobilization were initiated on the day of surgery.22 All the mentioned measures are directed toward a lower rate of complications that, associated with a faster recovery, allows a greater number of patients to receive the necessary adjuvant treatment in the postoperative period, which could provide the disease a better prognosis.

Despite surgical and oncological advances, gastric cancer continues to be a challenge due to its late diagnosis and poor prognosis. The new molecular classifications have subclassified gastric cancer into a heterogeneous group of diseases, which in the future could help better understand the disease and provide different therapeutic targets within the concept of personalized medicine.23 We should continue working along the same line with consensus guidelines, registries and communication of the results obtained. Projects like the EURECCA can help in this regard, as its aim is to advance toward the cure of a disease that is still a current concern.24

References
[1]
C.S. Fuchs, K. Muro, J. Tomasek, E. van Cutsem, J.Y. Cho, S.C. Oh, et al.
Prognostic factor analysis of overall survival in gastric cancer from two phase III studies of second-line ramucirumab (REGARD and RAINBOW) using pooled patient data.
J Gastric Cancer, 17 (2017), pp. 132-144
[2]
L. Kilic, C. Ordu, I. Yildiz, F. Sen, S. Keskin, R. Ciftci, et al.
Current adjuvant treatment modalities for gastric cancer: from history to the future.
World J Gastrointest Oncol, 8 (2016), pp. 439-449
[3]
Y. Liu, K.C. Zhang, X.H. Huang, H.Q. Xi, Y.H. Gao, W.Q. Liang, et al.
Timing of surgery after neoadjuvant chemotherapy for gastric cancer: impact on outcomes.
World J Gastroenterol, 24 (2018), pp. 257-265
[4]
J.H. Kim, Y.J. Bae, K.H. Jun, H.M. Chin.
Long-term trends in hematological and nutritional status after gastrectomy for gastric cancer.
J Gastrointest Surg, 21 (2017), pp. 1212-1219
[5]
J. Straatman, N. van der Wielen, M.A. Cuesta, E.S. de Lange-de Klerk, E.P. Jansma, D.L. van der Peet.
Minimally invasive versus open total gastrectomy for gastric cancer: a systematic review and meta-analysis of short-term outcomes and completeness of resection: surgical techniques in gastric cancer.
World J Surg, 40 (2016), pp. 148-157
[6]
H.J.F. Brenkman, S.S. Gisbertz, A.E. Slaman, L. Goense, J.P. Ruurda, van Berge Henegouwen MI., Dutch Upper Gastrointestinal Cancer Audit (DUCA) Group, et al.
Postoperative outcomes of minimally invasive gastrectomy versus open gastrectomy during the early introduction of minimally invasive gastrectomy in the netherlands: a population-based cohort study.
Ann Surg, 266 (2017), pp. 831-838
[7]
J.S. Azagra, M. Goergen, P. de Simone, J. Ibañez-Aguirre.
Minimally invasive surgery for gastric cancer.
Surg Endosc, 13 (1999), pp. 351-357
[8]
N. Van der Wielen, J. Straatman, M.A. Cuesta, F. Daams, D.L. van der Peet.
Short-term outcomes in minimally invasive versus open gastrectomy: the differences between East and West. A systematic review of the literature.
Gastric Cancer, 21 (2018), pp. 19-30
[9]
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Gastric Cancer, Version 3.2016, NCCN Clinical Practice Guidelines in Oncology.
J Natl Compr Canc Netw, 14 (2016), pp. 1286-1312
[10]
M. Degiuli, G. de Manzoni, A. di Leo, D. D’Ugo, E. Galasso, D. Marrelli, et al.
Gastric cancer: Current status of lymph node dissection.
World J Gastroenterol, 22 (2016), pp. 2875-2893
[11]
E.C. Smyth, M. Verheij, W. Allum, D. Cunningham, A. Cervantes, D. Arnold.
Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.
Ann Oncol, 27 (2016), pp. v38-v49
[12]
L. Arru, J.S. Azagra, O. Facy, S.T. Makkai-Popa, V. Poulain, M. Goergen.
Totally laparoscopic 95% gastrectomy for cancer: technical considerations.
Langenbecks Arch Surg, 400 (2015), pp. 387-393
[13]
Y.H.M. Claassen, H.H. Hartgrink, J.L. Dikken, W.O. de Steur, J.W. van Sandick, N.C.T. van Grieken, et al.
Surgical morbidity and mortality after neoadjuvant chemotherapy in the CRITICS gastric cancer trial.
Eur J Surg Oncol, 44 (2018), pp. 613-619
[14]
D.J. Kim, J.H. Lee, W. Kim.
A comparison of total versus partial omentectomy for advanced gastric cancer in laparoscopic gastrectomy.
World J Surg Oncol, 12 (2014), pp. 64
[15]
E.J. Jongerius, D. Boerma, K.A. Seldenrijk, S.L. Meijer, J.J.G. Scheepers, F. Smedts, et al.
Role of omentectomy as part of radical surgery for gastric cancer.
Br J Surg, 103 (2016), pp. 1497-1503
[16]
L. Haverkamp, H.J. Brenkman, J.P. Ruurda, F.J. Ten Kate, van Hillegersberg R..
The oncological value of omentectomy in gastrectomy for cancer.
J Gastrointest Surg, 20 (2016), pp. 885-890
[17]
T. Kinoshita, A. Kaito.
Current status and future perspectives of laparoscopic radical surgery for advanced gastric cancer.
[18]
P. Fugazzola, F. Coccolini, G. Montori, M. Ceresoli, P. Baggi, A. Costanzo, et al.
Overall and disease-free survival in patients treated with CRS+HIPEC with cisplatin and paclitaxel for gastric cancer with peritoneal carcinomatosis.
J Gastrointest Oncol, 8 (2017), pp. 572-582
[19]
B. Badgwell, M. Blum, P. Das, J. Estrella, X. Wang, K. Fournier, et al.
Lessons learned from a phase II clinical trial of laparoscopic HIPEC for gastric cancer.
Surg Endosc, 32 (2018), pp. 512
[20]
I. Songun, H. Putter, E.M. Kranenbarg, M. Sasako, C.J. van de Velde.
Surgical treatment of gastric cancer: 15-year follow-up results of the randomized nationwide Dutch D1D2 trial.
Lancet Oncol, 11 (2010), pp. 439-449
[21]
M. Degiuli, G. de Manzoni, A. di Leo, D. D’Ugo, E. Galasso, D. Marrelli, et al.
Gastric cancer: current status of lymph node dissection.
World J Gastroenterol, 22 (2016), pp. 2875-2893
[22]
W. Allum, J. Osorio.
El proyecto EURECCA para el cáncer gastroesofágico.
Cir Esp, 94 (2016), pp. 255-256
[23]
A.J. Bass, V. Thorsson, I. Shmulevich, S.M. Reynolds, M. Miller, B. Bernard, Cancer Genome Atlas Research Network, et al.
Comprehensive molecular characterization of gastric adenocarcinoma.
Nature, 513 (2014), pp. 202-209
[24]
M. Bruna Esteban, P. Vorwald, S. Ortega Lucea, J.M. Ramírez Rodríguez.
Rehabilitación multimodal en la cirugía de resección gástrica.

Please cite this article as: Azagra JS, Sarriugarte A, Ibañez FJ. Estado actual de la gastrectomía por cáncer. «Less is often more». Cir Esp. 2018;96:603–605.

Copyright © 2018. AEC
Article options
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

Quizás le interese:
10.1016/j.cireng.2022.04.010
No mostrar más