Surgical management of GASTRIC CANCER

Laparoscopic versus Open gastrectomy

Surgery is the only curative therapy for gastric cancer but most operable gastric cancer presents in a locally advanced stage characterized by tumor infiltration of the serosa or the presence of regional lymph node metastases. Surgery alone is no longer the standard treatment for locally advanced gastric cancer as the prognosis is markedly improved by perioperative chemotherapy. The decisive factor for optimum treatment is the multidisciplinary team specialized in gastric cancer. However, despite multimodal therapy and adequate surgery only 30% of gastric cancer patients are alive at 3 years.

Principles

The same principles that govern open surgery is applied to laparoscopic surgery. To ensure the same effectiveness of laparoscopic gastrectomy (LG) as conventional open gastrectomy, all the basic principles such as properly selected patients, sufficient surgical margins, standardized D2 lymphadenectomy, no-touch technique, etc., should be followed.

Indications

LG may be considered as a safe procedure with better short-term and comparable long-term oncological results compared with open gastrectomy. In addition, there is HRQL advantages to minimal access surgery. There is a general agreement that a laparoscopic approach to the treatment of gastric cancer should be chosen only by surgeons already highly skilled in gastric surgery and other advanced laparoscopic interventions. Furthermore, the first procedures should be carried out during a tutoring program. Diagnostic laparoscopy is strongly recommended as the first step of laparoscopic as well as open gastrectomies. The advantage of early recovery because of reduced surgical trauma would allow earlier commencement of adjuvant chemotherapy and the decreased hospital stay and early return to work may offset the financial costs of laparoscopic surgery.

The first description of LG was given by Kitano, Korea in 1994 and was initially indicated only for early gastric cancer patients with a low-risk lymph node metastasis. As laparoscopic experience has accumulated, the indications for LG have been broadened to patients with advanced gastric cancer. However, the role of LG remains controversial, because studies of the long-term outcomes of LG are insufficient. The Japanese Gastric Cancer Association guidelines in 2004 suggested endoscopic mucosal resection or endoscopic submucosal dissection for stage 1a (cT1N0M0) diagnosis; patients with stage 1b (cT1N1M0) and cT2N0M0) were referred for LG. Totally laparoscopic D2 radical distal gastrectomy using Billroth II anastomosis with laparoscopic linear staplers for early gastric cancer is considered to be safe and feasible. Laparoscopy-assisted total gastrectomy shows better short-term outcomes compared with open total gastrectomy in eligible patients with gastric cancer.

There was a significant reduction of intraoperative blood loss, a reduced risk of postoperative complications, and a shorter hospital stay. Western patients are relatively obese and there is an increased risk of bleeding if lymphadenectomy is performed. LG is technically difficult in the obese than in the normal weight due to reduced visibility, difficulty retracting tissues, dissection plane hindered by adipose tissue, and difficulty with anastomosis. Open gastrectomy is thus preferable for the obese. However, obesity is not a risk factor for survival of patients but it is independently predictive of postoperative complications. Careful approach is being needed, especially for male patients with high body mass index.

Robotic surgery

Robotic surgery will become an additional option in minimally invasive surgery. The importance of performing effective extended lymph node dissection may provide the advantage of using robotic systems. Such developments will improve the quality of life of patients following gastric cancer surgery. A multicenter study with a large number of patients is needed to compare the safety, efficacy, value (efficacy/cost ratio) as well as the long-term outcomes of robotic surgery, traditional laparoscopy, and the open approach.

Classroom: Surgical Management of Gastric Cancer

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