Spotlight on Surgery: Minimally Invasive Approaches to Treat Gastric Cancer

By Vivian Strong, MD

Memorial Sloan Kettering is the highest-volume referral center for gastric cancer in the United States. We care for more than 200 patients annually, approximately half of whom are eligible for surgical resection and undergo operations by our surgeons.

Our gastric surgeons have practices dedicated to operating on gastric cancer as a disease focus. This tremendous volume of cases allows for the establishment of a multidisciplinary group that is dedicated to the diagnosis, staging, and treatment of gastric cancer.

Known as the Gastric Disease Management Team (Gastric DMT), we meet regularly to review all cases and to discuss the management of difficult or unusual clinical situations as well as to provide consensus for plans of care. The team includes pathologists, surgeons, medical oncologists, and gastroenterologists – all with special interest and expertise in gastric cancer.

Our gastroenterologists also have the specialized skills to perform endoscopic ultrasound and – when appropriate for early cancers – to offer endoscopic mucosal resection to provide the most minimally invasive approach in many cases. Our medical oncologists have expertise in developing treatment plans specific to gastric cancer and will coordinate plans of care with outside oncologists that may be closer to a patient’s home, allowing for a more manageable and smooth treatment period. These factors all maximize the opportunity for the highest-quality evaluation and care for our patients.

Expertise in Minimally Invasive Surgery

As a high-volume gastric cancer specialty center we are also able to offer minimally invasive gastric resections with lymphadenectomy for selected patients. This program was developed by me in 2005 and has continued to grow. We have done more than 100 such operations and have continually refined the approach, making us one of the nation’s most experienced centers in this technique. Enlarge Image

In the Annals of Surgical Oncology in 2009 we reported finding comparable results between laparoscopic and open surgical approaches in a case control study of patients with resectable disease. In the study we compared operative characteristics and short-term oncologic and surgical outcomes of 30 patients undergoing laparoscopic gastrectomy for adenocarcinoma with all stages of resectable disease to outcomes of 30 patients undergoing open gastrectomy at our institution between 2005 and 2008.

Our analysis indicated that short-term oncologic results were equivalent in terms of margin status and adequate lymph node retrieval. Short-term recurrence-free survival was also comparable, but patients who underwent laparoscopic surgery experienced fewer postoperative complications and a shorter hospital stay.

Within the cohort analyzed, 33 patients (55 percent) had early-stage disease (Ia/Ib), 11 patients (18 percent) were stage II, 12 (20 percent) were stage IIIa, and four patients (6 percent) were stage IIIb. The median operative time was longer for the laparoscopic approach, compared to open surgery; 270 minutes versus 126 minutes. However, postoperative stays were shorter following laparoscopic gastrectomy compared with open surgery: five days versus seven days.

Most importantly, there were fewer early postoperative complications in the laparoscopic group (p = 0.07). There were also significantly more late complications for the open group following surgery. The incidence of late postoperative complications among patients in the laparoscopic group was 0 percent, compared to 20 percent (six patients) in the open group. Postoperative pain was also significantly lower in the laparoscopic group.

For oncologic outcomes, short-term recurrence-free survival and margin status were similar between the two groups, with adequate lymph node retrieval in both cohorts. The median number of lymph nodes resected following D2 dissection for laparoscopic surgery was 18 (range 7–36), while 21 (range 7–44) were resected through open surgery.

At a median follow-up of 11 moths, there were four cases of recurrence (13.3 percent) in the laparoscopic group versus five cases (16.6 percent) in the open surgery group at a median follow-up of 13.8 months. At 36 months, short-term recurrence-free survival was not significantly different between the laparoscopic and open groups.

Our experience has only grown since this study was published, and the laparoscopic approach is now being increasingly applied for patients at all stages of disease. We also offer robotic-assisted laparoscopic gastrectomy for selected patients.

  1. Viñuela EF, Gonen M, Brennan MF, et al. Laparoscopic versus open distal gastrectomy for gastric cancer: A meta-analysis of randomized controlled trials and high quality non-randomized studies, Ann Surg, 255(3):446-56, 2012.
  2. Strong VE. Laparoscopic resection for gastric carcinoma: Western experience. Surg Oncol Clin N Am, 21(1):141-58, 2012.
  3. Strong VE, Song KY, Park CH, et al. Comparison of disease-specific survival in the United States and Korea after resection for early-stage node-negative gastric carcinoma, J Surg Oncol, 107(6):634-40, 2013.
  4. Strong VE, Devaud N, Allen PJ, et al. Laparoscopic gastrectomy versus open gastrectomy for adenocarcinoma: a case-control study, Ann Surg Onc, 16(6):1507-13, 2009.
  5. Strong VE, Song KY, Park  CH, et al. Comparison of gastric cancer survival following R0 resection in the United States and Korea using an internationally validated nomogram. Ann Surg, 251(4):640-6, 2010.