Japan Digestive Disease Week 2022
Invited Lecture (JSGS)
October 29, 14:00–14:30, Room 4 (Fukuoka International Congress Center Maun Hall)
Invited Lecture-19
Current progress in minimal invasive surgery for advanced gastric cancer
- Department of Surgery, Seoul National University Hospital
Laparoscopic approach has been proved to be not inferior to open surgery in terms of long-term survival and with less short-term outcomes (KLASS-02, CLASS 01). Now with these scientific evidence, more laparoscopic approaches for locally advanced cancers are performed. There is one study on the comparison of laparoscopic vs. open total gastrectomy for AGC (KLASS-06) is on-going.
There are some concerns on laparoscopic approach in advanced gastric cancer (AGC) especially quite bulky cancer involving duodenum, T4a or T4b, conglomerated, sever fibrosis: #1. Resection margin? How do you determine distal and proximal margin in case of AGC. Surgeon’s palpation is an important assistant. When do the evaluation by frozen section? Lack of palpation sense which help surgeon for the determination of proper margins. #2. Cancer cell spillage: With more advanced cancer, it is more likely to have cancer cell loaded in the LNs as well as gastric wall (in case of T4a). #3. In case T4b, difficulty of extent of invasion and difficult to decide resectability. Especially, in case of severe fibrosis, laparoscopic dissection can be very difficult and high risk of injure vital vessels. #4. Fluorescence guided surgery can help? #5. How about cancer specific imaging? #6. Robot gastrectomy is laparoscopic surgery with robot instruments. The most important advantage of robot surgery would be using articulating devices. If we use the same ultrasonic energy device as in conventional laparoscopic approach, we can expect any difference in the patient outcomes. It has been demonstrated too. Although new articulating devices are available, still the results are not yet better than conventional laparoscopic devices.
Laparoscopic approach provides some benefit such as fine dissection with closeup view. But whenever there is doubt of margin or invasion to adjacent organ or structures, open surgery should be considered for the safety of patient. We do not have evidence yet for non-inferiority of laparoscopic approach in these kinds of situations including conversion surgery or gastrectomy post neoadjuvant chemotherapy.
There are some concerns on laparoscopic approach in advanced gastric cancer (AGC) especially quite bulky cancer involving duodenum, T4a or T4b, conglomerated, sever fibrosis: #1. Resection margin? How do you determine distal and proximal margin in case of AGC. Surgeon’s palpation is an important assistant. When do the evaluation by frozen section? Lack of palpation sense which help surgeon for the determination of proper margins. #2. Cancer cell spillage: With more advanced cancer, it is more likely to have cancer cell loaded in the LNs as well as gastric wall (in case of T4a). #3. In case T4b, difficulty of extent of invasion and difficult to decide resectability. Especially, in case of severe fibrosis, laparoscopic dissection can be very difficult and high risk of injure vital vessels. #4. Fluorescence guided surgery can help? #5. How about cancer specific imaging? #6. Robot gastrectomy is laparoscopic surgery with robot instruments. The most important advantage of robot surgery would be using articulating devices. If we use the same ultrasonic energy device as in conventional laparoscopic approach, we can expect any difference in the patient outcomes. It has been demonstrated too. Although new articulating devices are available, still the results are not yet better than conventional laparoscopic devices.
Laparoscopic approach provides some benefit such as fine dissection with closeup view. But whenever there is doubt of margin or invasion to adjacent organ or structures, open surgery should be considered for the safety of patient. We do not have evidence yet for non-inferiority of laparoscopic approach in these kinds of situations including conversion surgery or gastrectomy post neoadjuvant chemotherapy.