Total gastrectomy (TG) is one of the most invasive surgical procedures for patients with gastrointestinal malignancies. Needless to say, not only experience in the surgical technique but also careful postoperative management is required for patient safety and cure. According to the Japanese Gastric Cancer Treatment Guidelines published in 2010, surgical resection removing at least two-thirds of the stomach is recommended for a standard gastrectomy.1 Therefore, TG is selected for patients with gastric cancer located in the proximal stomach to maintain a sufficient oral surgical margin. Especially in advanced cases, because either the primary tumor or a metastatic lymph node (LN) may invade adjacent organs directly, a complicated resection is sometimes necessary to achieve a cure.
The two major severe complications after TG (pancreatic fistula and leakage of the esophagojejunal anastomosis) require intensive care to reduce the risk of mortality. The risk of pancreatic fistula is increased because injury to the pancreas may occur during LN dissection along the common hepatic and splenic arteries. Skilled techniques including removal of the pancreas serosa and mobilization of the spleen and pancreatic tail are needed to retrieve these LNs completely and safely. Katai et al.2 reported that LN dissection along the distal splenic artery in older obese patients was a risk factor for pancreas-related abscess after TG.
Costa et al.3 analyzed the outcomes of single-institution experiences with TG and reported a pancreatic fistula rate of 4.4 %. According to the results from an analysis of a Japanese nationwide Internet-based database, pancreatic fistula occurred in 2.6 % of patients after TG.4 As a speculative explanation for this narrow difference, we note that Western countries have more patients with intraabdominal fat than Asian countries, and it is sometimes difficult to discriminate the parenchyma of the pancreas from fatty tissue, including LNs.
Together with surgical skill, rescue treatment for postoperative complications is important to avoid an increased mortality rate. Early diagnosis of complications is expected for proper treatment. A previous report showed that measurement of the amylase level in the drainage fluid might be useful for the early diagnosis of pancreatic fistula.2 Nutritional support, infection control, and additional drainage depending on the abscess situation were required to manage the pancreatic fistula.
In the last decade of their study, Costa et al.3 noted that introduction of an esophagojejunal anastomosis with a stapler technique might decrease the rate of leakage. Their rate of esophagojejunal leakage was 4.4 %, the same as the result of the Japanese nationwide Internet-based database analysis.4 The mechanical stapling technique for anastomosis has been widely applied in digestive surgery with advantages. Nomura et al.5 described the existence of a learning curve with this technique, similar to that for the procedure of extended LN dissection, to decrease the complication rate. Thus, know-how and pitfalls exist for TG, as for any surgical procedure.
To date, splenectomy is recommended for completion of D2 LN dissection, including splenic hilar LN for proximal gastric cancer.1 In two European trials, splenectomy increased the risk of morbidity and mortality in gastrectomy.6,7 Therefore, an unresolved clinical question remains: Does splenectomy offer a survival benefit for proximal advanced gastric cancer?
Although several previous reports have described the significance of splenectomy, its clinical impact remains controversial.8,9 In Japan, a large randomized controlled study (JCOG0110) evaluating the role of splenectomy in TG for advanced proximal gastric cancer was conducted.10 Although the final results for overall survival are not available to date, the outcomes of surgery and mortalities have been reported.10 One death occurred in the splenectomy group (0.4 %) and two deaths (0.8 %) in the spleen preservation group. Although the operative times did not differ significantly between the two groups (231 vs. 224 min), blood loss was greater in the splenectomy group than in the spleen-preservation group (390.5 vs. 315 ml; p = 0.02). In addition, the splenectomy group had greater morbidity (30.7 %) than the spleen-preservation group (16.7 %) (p < 0.001). In the splenectomy group, the rate of pancreatic fistula was 12.6 %, and the incidence of leakage from the gastrojejunal anastomosis was 4.3 %. In the spleen-preservation group, the rate of pancreatic fistula was 2.4 %, and the incidence of leakage from the gastrojejunal anastomosis was 3.2 %. The final results of overall survival may clarify the clinical benefit for proximal gastric cancer.
For patients with early gastric cancer, laparoscopic surgery has been the treatment of choice as a minimally invasive treatment. Kitano et al.11 reported the first case of laparoscopically assisted distal gastrectomy for early gastric cancer. However, there are technical issues with laparoscopic gastrectomy regarding reconstruction, especially with the esophagojejunal anastomosis.
Recent improvement in anastomosis devices and modifications of various anastomotic techniques have enabled safe performance of esophagojejunostomy, and surgeons have begun to perform laparoscopically assisted TG. In particular, the circular stapler with a transorally inserted anvil, which closely approaches conventional anastomosis by laparotomy, has enabled esophagojejunostomy.12 Although laparoscopically assisted total gastrectomy could be applied technically, no data exist to indicate that a laparoscopic approach in total gastrectomy is sufficient oncologically. Clinical trials are needed to establish this evidence.
Indeed, oncologic surgery must be safe and show good operative outcomes without compromising curability. Because both previous and ongoing randomized controlled trials have been limited to certain institutions and surgeons, it is difficult to use the results from these clinical trials to establish a standard treatment. As shown by Costa et al.,3 total gastrectomy for gastric cancer is safe and feasible if performed by skilled surgeons who practice at high-volume centers. Hence, postoperative management is considered to be as important as experienced surgical technique.
References
Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma. 3rd ed. Gastric Cancer. 2011;14:101–12.
Katai H, Yoshimura K, Fukagawa T, Sano T, Sasako M. Risk factors for pancreas-related abscess after total gastrectomy. Gastric Cancer. 2005;8:137–41.
Costa WL Jr, Ribeiro H, Diniz A, et al. Total gastrectomy for gastric cancer: an analysis of postoperative and long-term outcomes through time. Ann Sur Oncol. 2014. doi:10.1245/s10434-014-4212-6.
Watanabe M, Miyata H, Gotoh M, et al. Total gastrectomy risk model: data from 20,111 Japanese patients in a nationwide Internet-based database. Ann Surg. 2014 [Epub ahead of print]. doi:10.1097/SLA.0000000000000781.
Nomura S, Sasako M, Katai H, Sano T, Maruyama K. Decreasing complication rates with stapled esophagojejunostomy following a learning surve. Gastric Cancer. 2000;3:97–101.
Bonenkamp JJ, Songun I, Hermans J, et al. Randomized comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet. 1995;345:745–8.
Cuschieri A Fayers P, Fielding J, Craven J, Bancewicz J, Joypaul V, Cook P, for the Surgical Cooperative Group. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. Lancet. 1996;347:995–9.
Csendes A, Burdiles P, Rojas J, Braghetto I, Diaz JC, Maluenda F. A prospective randomized study comparing D2 total gastrectomy versus D2 total gastrectomy plus splenectomy in 187 patients with gastric carcinoma. Surgery. 2002;131:401–7.
Wanebo HJ, Kennedy BJ, Winchester DP, Stewart AK, Fremgen AM. Role of splenectomy in gastric cancer surgery: adverse effect of elective splenectomy on long-term survival. Am Coll Surg. 1997;185:177–84.
Sano T, Sasako M, Shibata S, et al. Randomized controlled trial to evaluate splenectomy in total gastrectomy for proximal gastric cancer (JCOG0110): analyzes of operative mortality, operation time, and blood loss. J Clin Oncol. 2010;28(Suppl):15s.
Kitano S, Shimoda K, Miyahara M, et al. Laparoscopic approaches in the management of patients with early gastric carcinomas. Surg Laparosc Endosc. 1995;5:359–62.
Hirahara N, Tanaka T, Yano S, et al. Reconstruction of the gastrointestinal tract by hemi-double stapling method for the esophagus and jejunum using EEA OrVill in laparoscopic total gasrtectomy and proximal gastrectomy. Surg Laparosc Endosc Percutan Tech. 2011;21:e11–5.
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Takahashi, T., Takeuchi, H. & Kitagawa, Y. What Factors Are Necessary for the Safe and Feasible Performance of Total Gastrectomy?. Ann Surg Oncol 22, 704–705 (2015). https://doi.org/10.1245/s10434-014-4227-z
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DOI: https://doi.org/10.1245/s10434-014-4227-z