Available online at www.sciencedirect.com
EJSO 35 (2009) 281e288
www.ejso.com
Outcomes and survival after laparoscopic gastrectomy for
adenocarcinoma. Analysis on 65 patients operated on by
conventional or robot-assisted minimal access procedures
R. Pugliese*, D. Maggioni, F. Sansonna, G.C. Ferrari, A. Forgione, A. Costanzi,
C. Magistro, J. Pauna, S. Di Lernia, D. Citterio, C. Brambilla
Divisione di Chirurgia Generale e Videolaparoscopica, Ospedale di Niguarda Ca’ Granda, Milano, Italy
Accepted 4 February 2008
Available online 14 March 2008
Abstract
Aims: Despite laparoscopic surgery for gastric cancer has gained worldwide acceptance, long term results and survival are seldom reported.
This study was designed to assess long term outcomes after laparoscopic gastrectomy with D2 dissection. The short term results of conventional and robot-assisted minimally invasive procedures were also examined.
Patients and methods: The charts of 65 patients who underwent laparoscopic surgery for non-metastatic adenocarcinoma were reviewed
retrospectively. This series included 35 patients with early gastric cancer (EGC) and 30 with advanced gastric cancer (AGC). A 4/5
laparoscopic subtotal gastrectomy (LSG) with D2 nodal clearance was the procedure of choice for distal cancers. Laparoscopic total gastrectomy (LTG) with modified D1 lymphadenectomy was performed for mid-proximal EGC.
Results: Sixty gastrectomies were carried out laparoscopically, 56 LSG and 4 LTG. Conversion to laparotomy was required in 5 patients
with distal cancer. No intraoperative complication was registered. Morbidity included 2 duodenal leaks that healed conservatively. Two
postoperative deaths were registered. An average number 31.3 8.8 lymph nodes were collected. The mean hospital stay was 10 days
(range 7e24). The mean follow up was 30 months (range 2e86) and the cumulative overall 5 year survival rate was 78%. Survival at
5 years for EGC was 94% and survival at 4 years for AGC was 53% (57% for non-converted patients).
Conclusions: Laparoscopic gastrectomy for cancer represents a valid alternative to open surgery with minimal morbidity and acceptable
long term survival. Considering the risk of preoperative under diagnoses a D2 lymphadenectomy is suggested also for EGC. This study
validated the effectiveness of minimally invasive technique in the management of gastric cancer.
Ó 2008 Elsevier Ltd. All rights reserved.
Keywords: Gastric cancer; Laparoscopy; Gastrectomy; Lymphadenectomy; Long term survival
Introduction
The respect for oncological principles is crucial when
dealing with gastric cancer. Currently, performance of extended (D2) lymphadenectomy is advocated although in absence of randomized studies.1e7 Some Authors consider
also paraortic D3 dissection and adjuvant therapies as potential benefits to survival.7e11 When gastric adenocarcinoma is resected by minimal access procedures the
support of endoscopic ultrasonography in the preoperative
* Corresponding author. Chirurgia Generale e Videolaparoscopica, Ospedale Niguarda Ca’ Granda, Piazza Ospedale 3, 20162 Milano, Italy.
Tel.: þ39 02 6444 2503; fax: þ39 02 6444 2905.
E-mail address: chirurgiaurgenza@ospedaleniguarda.it (R. Pugliese).
0748-7983/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ejso.2008.02.001
staging plays an important role.12 According to the Guidelines of the Japanese Gastric Cancer Association (JGCA)
laparoscopic gastrectomy is a valid alternative to open surgery for early gastric cancer (EGC) but it is controversial
for advanced gastric cancer (AGC) in which performance
of a correct lymphadenectomy is much more important.3,13
Relapse is generally hematogenous for EGC with a rate of
lymph node metastases of 0e10% in mucosal and 11e42%
in submucosal carcinomas, hence lymphadenectomy might
be regarded as an overtreatment in around two thirds of
cases.14e20 Moreover, in patients older than 75 years extended lymphadenectomy may be even unnecessary.21 Despite this data, pre-operative understaging has been
reported and enhanced the need for D2 lymphadenectomy
also in EGC.22,23 Laparoscopic gastrectomy has been
282
R. Pugliese et al. / EJSO 35 (2009) 281e288
carried out for AGC with good short term outcomes, but
large-scale studies are still lacking.24e44 Moreover, the laparoscopic management of gastric malignancies remains
open to debate and little data on long term survival is available.31,32,43 The main purpose of this study was to analyze
long term results of EGC and AGC treated by minimally invasive technique over a period of 7 years. The endpoints
were 5 year survival and disease free intervals. The short
term results of LSG by conventional laparoscopy and
robot-assisted laparoscopy were analyzed.
Our profile of learning curve
Patients and methods
Study population
Since June 2000 through September 2007 a total of 215
patients were referred to our Unit for gastric carcinoma of
any stage, including 181 men and 34 women with mean age
of 70 years (range 40e85). The overall incidence of EGC
in our series was 16% (35/215).
The data of 65 patients is illustrated in Table 1. The
surgical risk was reckoned by the American Society of
Anesthesiology (ASA) score. EGC were 1.84 cm in size
(range 0.8e4) and AGC 4.6 cm (range 3e10). Among
35 EGC, 31 were located in the lower third, 68% were
Lauren’s intestinal type and 65% were well differentiated.
One patient was affected both by EGC and right colonic
cancer and underwent LSG and laparoscopy-assisted right
hemicolectomy. All of the 30 AGC recruited for laparoscopic excision were located in the lower third of the
stomach.
Eligibility criteria for laparoscopic surgery
Subjects with histologically confirmed EGC or nonmetastatic distal AGC, in good general conditions, were
included in this study. Subjects with distant metastases,
preoperative evidence of local infiltration, AGC of the upper two thirds of the stomach, anaesthesiologic contraindications and previous laparotomies for major
abdominal surgery were not considered eligible for laparoscopic approach. Open gastrectomy was carried out in
124 patients with D2 dissection (D2 þ D3 paraortic in
26 cases).
Procedures
Sixty-five patients, 40 men and 25 women of mean age
of 72 years (range 41e86) were enrolled for laparoscopic
procedures, 35 affected by EGC and 30 by AGC. All these
patients were asked for informed consent before surgery.
Conventional laparoscopy (CL) or robot assisted laparoscopy (RAL) was employed and all the operations were performed by the same surgeon. All of the EGC beneficiated
of laparoscopic surgery that until January 2006 was performed only by CL. Laparoscopic subtotal gastrectomy
(LSG) was performed for distal EGC or distal AGC with
extended D2 dissection according to the latest JGCA
classification.13
To date, AGC of cardia or proximal regions of the stomach have been treated by open surgery to ensure a correct
D2 or D3 dissection. Laparoscopic total gastrectomy
(LTG) with modified D1 dissection was carried out for
mid-proximal EGC by CL. The Roux-en-Y loop was the
preferred method of reconstruction of the digestive tract.
Kodama’s criteria were used for histologic classification
of EGC18 and tumor staging was obtained according to
UICC-TNM classification (2002) of the International Union
Against Cancer.
We started by CL in patients >75 years with cancers like
EGC not requiring extensive lymphadenectomy,13,14,21 then
turned to distal AGC only after developing enough skill
maturation in performance of D2 dissection. Then, LTG
with modified D1 for EGC ensued, but in the future we
aim at approaching mid-proximal AGC by LTG with D2
dissection as the final goal of our learning curve in laparoscopic surgery of the gastric cancer.
Preoperative work up and patients’ preparation
Preoperative investigations included endoscopy with biopsy and vital staining, abdominal echography and helicalcomputed tomography (CT). In case of EGC the tumor was
marked endoscopically with Indian Ink to identify the lesion during laparoscopy, and was staged by ultrasound endoscopy with a 15 MHz probe. All the AGC were staged by
endoscopy, biopsy and CT-scan. Preparation consisted in
SinaireÒ (Promefarm srl, Milan) 6 tablets a day for
4 days before admission, plus 4 l of Polietilenglycole acid
(PEG) 2 days before surgery. SeleparinaÒ (Italfarmaco, Milan) 0.3 ml was given subcutaneously the night before surgery for anti-thrombotic prophylaxis and Cephazoline 6 g
i.v. was administered the day of surgery for short term
antibioprophylaxis.
Statistical analysis
Data was derived retrospectively from the database and
elaborated by SPSS statistical analysis software package
(version 11.0). Continuous variables were analyzed by Student t-test and discrete variables by Chi square test or Fisher’s Exact Test. Values of P < 0.05 were considered
significant within a confidence interval (CI) of 95%. Long
term actuarial survivals were determined by KaplaneMeier
estimator and were elaborated by JMP 5.1.1 version of SAS
Institute. Statistical differences in survival between groups
were identified by the log-rank test. The patients operated
on by RAL were all included in the statistical elaboration
of long term results.
R. Pugliese et al. / EJSO 35 (2009) 281e288
Table 1
Laparoscopic procedures in early gastric cancer (EGC) and advanced gastric cancer (AGC)
ECG (¼35)
AGC (¼30)
Age
Gender
Mean (range)
Men
Women
68 years (41e84) 77 years (71e86)
21
19
14
11
ASA score
I
II
III
5
19
11
0
17
13
Location
Upper
Middle
Lower
2
2
31
0
0
30
pTNM
pT1mN0M0 (IA) 29
(UICC 2002) pT1smN0M0 (IA) 4
(2 Pen B, 2
small mucosal
SM)
pT1smN1M0 (IB) 1 Pen A
pT2N0M0 (IB)
pT1smN2M0 (II) 1 Pen A
pT2N1M0 (II)
pT2N2M0 (IIIA)
pT3N1M0 (IIIA)
pT2N3M0 (IV)
15
6
5
3
1
Data of 65 patients. Niguarda Hospital, Milan (2000e2007). Pen
B ¼ penetrating B, Pen A ¼ penetrating A, SM ¼ small mucosal, according to Kodama’s classification of submucosal early gastric cancers.18
Surgical technique of conventional LSG and LTG
The surgical techniques of conventional LSG and LTG
are the same described in a previous issue of ours,23 using
trocars of 10 mm (X-celÒ Ethicon Endo-Surgery Inc, Cincinnati, OH). All the dissecting manoeuvers are conducted
by ultrasonic scalpel either with a shaft of 10 mm (UltracisionÒ Ethicon, Cincinnati, OH) or with a shaft of 5.5 mm
(Harmonic AceÒ Ethicon, Cincinnati, OH). Titanium clips
(LigaclipÒ12-L endowed with rotating clip applier, Ethicon
Endosurgery Inc, Cincinnati, OH) or absorbable clips (LaproclipÒ, Tyco Healthcare Group, Norwalk, USA) are used
on vessels. Gastric dissection, D2 lymphadenectomy and
closure of duodenum are the first steps of operations. For
LTG a side-to-side esophagojejunal anastomosis is fashioned reproducing Orringer’s model.45 We shortly describe
the technique of LSG by RAL.
Robot assisted LSG
The patient is in supine position the same as for conventional LSG. The telesurgery robotic cart is a 3-armed Robotic Surgical System (Robot da VinciÒ Intuitive
Surgical, Mountain View, CA, USA) controlled from a remote console. Robot and optic system setup are prepared.
Electric cables connect the robotic system and after
a self-test the 3 arms are wrapped with covers and fixed
by supports. A 3D image is selected, then a 12 mm cannula
283
is inserted in supraumbilical site for open laparoscopy and
optic view. Then under direct vision 3 ports of 12 mm are
inserted in the upper quadrants. One robotic port of 7 mm
is created for other instruments. The robotic cart is installed. For the first steps a wide view is necessary, thus
they are conducted under CL: omentectomy, coloepiploic
detachment, opening the lesser sac, gastroduodenal dissection and ablation of inphrapyloric nodes (tiers 4 and 6).
Then, the second jejunal loop is prepared to fashion the
side-to-side stapled anastomosis at the foot of the Rouxen-Y loop. When the robotic system is ready, lymphadenectomy is conducted on the anterior aspect of hepatic artery
(group 12a), then the right gastric artery is cut, the suprapyloric nodes are removed (group 5) and the duodenum
is transected by a 45 mm linear cutting stapler reinforced
with SeamguardÒ bioabsorbale policarbonate material
(W.L. Gore & Associates, Inc. Flagstaff, Arizona) for reinforcement of the staple line. Lymphadenectomy is completed by ablation of nodal tiers 8, 9, 11p followed by
division of left gastric artery with removal of group 7 and
tiers 1, 3 and 5 along the lesser curvature. The stomach is
transected by linear stapler to obtain a 4/5 gastrectomy
leaving temporarily the specimen in the peritoneal cavity.
A 50 cm. Roux-en-Y jejunal limb is chosen for restoration
of the digestive tract. A transmesocolic gastro-jejunal anastomosis is fashioned with a linear cutting stapler on the posterior wall of the gastric stump. The access openings are
closed by separated extracorporeal slipknots. The endobag
(Endocatch IIÒ 15 mm Ethicon Endo-Surgery Inc, Cincinnati, OH) containing the resected stomach with D2 lymphatic stations is retrieved through the enlarged umbilical
port. A drain is placed near duodenal stump in Morrison’s
pouch and closure of port incisions ends the operation.
Results
Short term results
A 4/5 LSG with D2 dissection was carried out in 56 distal
cancers, totally intracorporeal in 55 (Tables 2 and 3) and
video-assisted in 1 in which the gastrojejunal anastomosis
was fashioned through a small midline incision. Intracorporeal LTG was carried out by CL in 4 EGC with no conversion.
Conversion was required in 5 distal cancers (7.6%) for difficult dissection of 4 AGC and anatomical problems in 1 EGC.
The conversion rate for LSG was 6.5% by CL and 18% by
RAL. No intraoperative complication was registered. Overall, the mean operating time of LSG was 254 16 min.
Mean duration of LTG was 275 22 min (range 165e410).
The estimated mean blood loss was 146 55 ml for LSG
and 180 94 ml for LTG. Specific morbidity was 4.6%,
comprising 2 duodenal stump leaks after CL (incidence
3%): both leaks healed conservatively and occurred at the
very start of this study, when the stump was just stapled,
but after enclosing the staple line by separated stitches or reinforcing it by SeamguardÒ stump leaks weren’t observed
284
R. Pugliese et al. / EJSO 35 (2009) 281e288
Table 2
Outcomes of 65 laparoscopic procedures for early and advanced gastric
adenocarcinoma
EGC
(n ¼ 35)
AGC
(n ¼ 30)
Surgical
procedure
Mean number of nodes
harvested (range)
Resection margin
4 LTG
30 LSG
29.7 7 (20e40)
34 free of disease
1 LSG
converted
33
1 free of disease
26 LSG
32.5 9.7 (28e45)
25 free of disease
1 infiltrated
4 LSG
converted
34.6 8 (30e48)
3 free of disease
1 infiltrated
A preoperative diagnosis of mucosal EGC was made in
38 patients. The histologic examination on the surgical
specimen disclosed an AGC in 3 cases and a submucosal
EGC in 6 (Table 1). Hence, under diagnosis occurred in
23.7% of cases (9/38). Sensitivity for any EGC was
100% and accuracy 95%. Sensitivity for mucosal EGC
was 100% and accuracy 86%, with a positive predictive
value of 76.3% for pT1m. Anyway, subtotal gastrectomy
with D2 dissection was routinely carried out also in cases
underestimated by preoperative investigations.
Short term result of robot assisted LSG
Niguarda Hospital, Milan (2000e2007).
any more. One pancreatic leak, but no duodenal leak occurred in the RAL group. Mortality rate (within 30 days)
was 3%, due to 1 anastomotic bleeding in a patient with cirrhosis after LSG by CL and to 1 haemorragic stroke after
LSG by RAL, both carried out for EGC. The mean LOS
(length of hospital stay) was 10 3 days (range 7e24).
The mean LOS for LTG was 11.6 2 days and the difference with the mean hospital stay of LSG (Table 3) was not
statistically relevant (P > 0.05). The average distance of
the resection margin was 6.7 0.68 cm (range 4e8.5 cm)
with no significant difference between CL and RAL.
The resection margin was involved in 2 cases of Lauren’s
infiltrating carcinoma (Table 2). In the first ten procedures
for EGC were retrieved 20 nodes and in the first ten procedures for AGC 25 nodes. An average number of 31.3 8.8
lymph nodes (range 18e45) was collected by laparoscopic
gastrectomies, as detailed in Table 2; the mean number of
nodes harvested by LTG was 35 4. Nodal metastases
were found in 2 Pen A type distal EGC (incidence 6.4%):
all the nodes involved were collected from the lesser curvature, with a ratio (number of metastatic nodes/number of
nodes retrieved) respectively of 3/40 (N1) and 10/25 (N2).
In this study subtotal gastrectomy by RAL was attempted in 11 patients (6 women and 5 men) of mean age
68 years (range 45e82). The mean size of lesions was
3.2 2.6 cm (range 0.8e10 cm). Conversion was required
in 2 cases for difficulties in dissection (conversion rate
18%): in one EGC owing to a hepatic artery of 7 mm in diameter arising from the left gastric artery, and in one AGC
(pT2N2) for tumor size. No intraoperative complication
was registered. The mean time for robot system setup dropped from 40 to 15 min within 2 years. The robotic system
was prepared in 23 8 min on average (range 15e40)
and the mean duration of RAL was 170 45 min (range
120e240). Average LOS was 11 days. The differences
between short term results of CL and RAL, excluding converted patients (Table 3), were not statistically relevant
(P > 0.05). The post-operative morbidity consisted in 1
pancreatic leak that healed conservatively in 40 days. Mortality concerned 1 patient with EGC who died from haemorragic stroke. The resection margin was 6.7 cm on
average and margins were all free of disease on histologic
examination; the mean number of nodes retrieved by robot
assisted LSG was 27.5 5 (range 18e40).
Outline of follow up
Conventional LSG
Robot assisted LSG
n ¼ 46
n¼9
The follow-up included controls scheduled on a 6 month
basis for 5 years, including clinical examination, abdominal
echography and monitoring of CEA and CA 19/9 cancer
antigens serum levels. Endoscopy or CT scan were required
when the suspicion of relapse was raised by clinical examination, echography or laboratory findings.
(25 EGC, 21 AGC)
values (range)
(4 EGC, 5 AGC)
values (range)
Long term results and survival
236 20 (145e360)
156 57 (45e250)
1.2 0.7
350 71 (240e460)
92 58 (50e200)
1.2 0.5
5 0.8
10 2.5 (7e24)
31.5 9.5 (20e45)
5 1.1
11 1 (10e13)
27.5 5 (18e40)
Table 3
Short term outcomes of 55 patients after conventional and robot assisted
subtotal gastrectomy by thorough intracorporeal technique
Operating time (minutes)
Blood loss (ml)
Times to mobilization
(p.o. day)
Oral intake (p.o. day)
Hospital stay (days)
Mean number of nodes
harvested by D2
Accuracy of preoperative staging
Niguarda Hospital, Milan (2000e2007).
The mean follow up after surgery was 35 20.7 months
(range 2e86). Excluding 2 postoperative deaths, survival
was reckoned on 63 patients: 4 of them were lost to follow
up. The 5 year cumulative overall survival (OS) was 78% as
shown in Fig. 1. The follow up span was 7 years for EGC
and 4 years for AGC: stratified survivals are illustrated in
Fig. 2 and the differences were statistically significant
R. Pugliese et al. / EJSO 35 (2009) 281e288
285
Comment
Short term results
Figure 1. Cumulative long term survival of laparoscopic gastrectomy for
adenocarcinoma (2000e2007).
with the log rank test (Mantel-Cox). Four year OS of patients with distal AGC was 53%, but it was 57% for those
not converted. Eleven patients had recurrence (18.6%) and
6 of them died of disease, one affected by EGC and 5 by
AGC (Table 4). One patient undergoing video-assisted
LSG for EGC Pen A type died for carcinosis (n 1 in Table
4). Another patient with EGC Pen A type was alive and disease free 2 months after RAL. Two patients had the resection margin involved by Lauren’s infiltrating type
carcinoma and were reoperated on (n 8 and 9 in Table
4). Fourteen patients with N1eN3 advanced cancer underwent postoperative adjuvant chemotherapy, while one patient converted (pT3N1) could not beneficiate of adjuvant
therapy for medical contraindications (n 2 in Table 4).
Four patients affected by poorly differentiated AGC died
from disease after totally intracorporeal LSG by CL (n
3, 4, 5, 6 in Table 4). No port site metastasis was observed
in this study. The mean disease free interval of the 6 patients deceased was 17 months (range 3e30) with a mean
survival of 22 months (range 8e38). These periods were respectively 20 months (range 9e30) and 25 months (range
12e38) for the 4 patients beneficiating of totally intracorporeal LSG. To date, no death for disease was registered
after totally intracorporeal LSG by RAL in 8 patients after
a mean follow up of 8 months (range 2e18). Disease free
OS was 94% for EGC and 51% for AGC (P ¼ 0.0048
with the log-rank test).
Figure 2. Gastric cancer by laparoscopic approach: survival for EGC (at
5 years) and for AGC (at 4 years).
Our short term results compared favourably with those
of other series. No intraoperative complication was registered. The overall conversion rate was 7.6% (6% for CL),
with a 0%e10% rate reported in other series.28,30,34e36,41e44 The mean operating time of LSG by CL
was 236 min, ranging between 200 and 320 min in the literature.24,29e36,41 The mean operating time of LSG by RAL
was 350 min, ranging from 420 to 656 min in other reports.39e41 Estimated mean blood loss was 148 ml, 156 ml for
CL and 92 ml for RAL, ranging from 65 to 300 ml in other
series.32e36,39,40 Specific morbidity was 4.6%, ranging from
3.8% to 26.7% in the literature.22,25,30e35,36,43 Mortality
was 3%, varying between 0% and 9% in laparoscopic reports.30,31,33,35,36,41e44 Recently, a mortality rate of 4e6%
has been reported in a large study on open gastrectomy.10
Average LOS was 10 days, comparable to the 7e17 days
LOS reported in other studies.24,29,30e44 Compared to CL,
RAL did not result in higher morbidity or in longer LOS.
Long term results
The main endpoints of our study have been long term results after laparoscopic gastrectomy.
To authors’ knowledge this is the third issue including
both EGC and AGC and reporting survival rates. However,
Huscher’s and Tanimura’s studies31,32 reported only cumulative survival rates which are biased by the proportion of EGC
included, while this study reported also the stratified survivals of EGC and AGC. The 5 year cumulative OS was
78% in our series, consisting of EGC in more than half cases.
Focusing only on antropyloric AGC, the 4-year OS was 53%
(Fig. 2) but it was 57% excluding converted patients, a result
consistent with other reports.6,31,32,46 To date, it has been
described only one case of port-site recurrence after laparoscopic gastrectomy,47 but no port site metastasis was
observed in this study.
Lymph node harvest
Shimizu and Adachi reported in the year 2000 that there
was no difference in nodal clearance between laparoscopic
and open surgery.22,48 The mean number of nodes collected
in our study was 31, ranging from 15 to 43 in the literature.22,24,30e36,42 Thus, D2 dissection complied with JGCA
criteria and also with Western criteria of a minimum of 25 nodes retrieved.49 The mean number of nodes collected by RAL
was 27, comparable to that reported in a recent issue.40 At the
outset of our experience with CL the mean number of nodes
collected was even smaller: in the first ten procedures for
EGC were retrieved 20 nodes and in the first ten procedures
for AGC 25 nodes. We are confident that with progression of
the learning curve RAL will afford the same number of nodes
286
R. Pugliese et al. / EJSO 35 (2009) 281e288
Table 4
Long term results of 11 patients with recurrence of disease
Tumor
Operation
Disease free
interval (months)
Reoperation
for relapse
1
2
pT1N1
pT3N1
D2 LSG
Converted
21
3
3
4
5
6
7
pT2bN2
pT2bN1
pT2bN2
pT2bN0
pT2bN2
D2 LSG
D2 LSG
D2 LSG
D2 LSG
RA converted (TG)
8
19
21
30
6
8
9
10
11
pT2bN0
pT3N1
pT3N1
pT2N1
Converted (TG)
D2 LSG
D2 RA LSG
D2 RA LSG
42
13
12
5
No
Exploratory
laparotomy
No
No
No
No
Exploratory
laparotomy
Oesophagectomy
Degastrectomy
Hysteroadnexectomy
No
Alive
(months after
gastrectomy)
Deceased
(months after
gastrectomy)
27
8
12
24
27
38
8
57
21
12
10
LSG ¼ laparoscopic subtotal gastrectomy; TG ¼ total gastrectomy; RA ¼ robot-assisted.
Follow-up span June 2000eSeptember 2007.
retrieved by CL. On the other hand, the role of extended lymphadenectomy still is debated.2,14,20,21 A randomized study
comparing extended D2 versus super extended D3 lymphadenectomy has been conducted in Japan, but apart from short
term results, to the best of authors’ knowledge survival and
long term results of this study still await publication.3,7,8
Some Japanese Authors maintain that JGCA classification
is more suitable than UICC-TNM classification for estimating prognosis of patients with AGC.4 Lymphadenectomy in
EGC can identify the high-risk population with worse prognosis, independent of its influence on survival,50 although in
the vast majority of mucosal EGC a D1 dissection with removal of 1, 3e6 stations according to JGCA would suffice13
and D2 for well differentiated mucosal EGC <4.5 cm in size
has been considered unnecessary.14 Despite this data, there
are still good reasons to suggest a routine D2 dissection for
EGC, i.e. under diagnoses.
Extent of resection
mucosal were submucosal on histologic examination.22 In
this study preoperative misdiagnosis occurred in 23.7% of
cases, leaving 3 AGC undiagnosed and 6 submucosal EGC
under staged. Anyway, D2 dissection was carried out routinely in all distal cancers and because the frequency of nodal
involvement of distal EGC was 6.4% with hindsight it must
be emphasized how D2 has been appropriate in cases underestimated preoperatively. In a study by Kitano the frequency
of nodal involvement after distal gastrectomy for EGC, in
absence of a routine D2 dissection, was 6.6%,43 a value comparable to that of our study in which for distal EGC a routine
D2 was performed although nodal metastases were all from
the lesser and the greater curvature, that is, within the reach
of D1 dissection. To summarize, because under diagnosis left
undetected 3 AGC and understaged 6 submucosal EGC in
our experience, we maintain that, until accuracy of preoperative staging is 100%, performance of LSG with D2 lymphadenectomy remains justified.
Conclusions
Distal gastrectomy has been generally carried out for
EGC of the lower third.25e29,32,33,36,43 However, subtotal
gastrectomy with a 6 cm margin has been recommended
for distal cancers, also for EGC.19,30,31,40,51 It has been reported a 2.2e23.1% incidence of multifocal EGC and this
factor regards especially elderly patients affected by intestinal or differentiated type of carcinoma of the lower
third.15,19,52,53 In our series 68% of EGC were intestinal
type, 65% were well differentiated and the mean age of patients was 68 years (Table 1), hence a minimum safety margin of 6 cm was warranted. Moreover, subtotal gastrectomy
yields the performance of a correct D2 dissection including
the right paracardial nodes (tier 1).
The problem of preoperative under diagnoses
Under diagnoses do represent a major problem: Shimizu
reported that 29% of EGC diagnosed preoperatively as
This study reported survivals after laparoscopic gastrectomy stratified for EGC and AGC, a data seldom found in
other reports today. Oncologic principles of lymph node
harvest and extent of resection were respected. Our long
term results confirmed that laparoscopic surgery represents
a reliable alternative to open procedure in the treatment of
gastric cancer.
Conflict of interest
We hereby declare that there is no potential or actual
personal, financial or political interest related to this article.
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