Laparoscopic gastrectomy is being compared to open gastrectomy for gastric cancer treatment. Several studies show that laparoscopic and open approaches have comparable short-term surgical outcomes in terms of complication rates. Regarding long-term oncologic outcomes, multiple studies found no differences in the number of retrieved lymph nodes or disease-free and overall survival rates between the two approaches. While the laparoscopic approach has a learning curve of around 20 cases, it provides better post-operative quality of life measures like less pain and earlier return of bowel function.

1. Can the laparoscopic approach to D2
gastrectomy be justified? An evidence
update“
• Dr . Mutaz al makhamrah
• Surgical oncology fellow
• KHCC
• Surgical oncology department

2. HISTORY
First Gastrectomy for GC – BILLROTH
Lap wedge resection for EGC - Ohgami
Lap Distal Gastrectomy for Ca - Kitano
Lap Total Gastrectomy for
Ca - Azagra
KLASS I
JCOG 0912
1881 1992 1994 1996
2015

3. Epidemiology
• Gastric cancer (GC) is the fourth most common cancer worldwide
• second most common cause of cancer-related death in the world (700,000 deaths annually).
• Almost two thirds of cases occur in developing countries, with China alone accounting for 42%.
• The incidence in the Middle East countries is relatively low, with rates 5–15 times lower than in
Japan.
• The Jordan Cancer Registry (JCR) indicated that gastric cancer was the tenth most common
cancer in Jordan, accounting for 2.7% of all tumors.
•

4. World map showing estimated 2008 male age-standardized (world) incidence rates per 100,000 by country for gastric cancer. (From Ferlay J, Shin
HR, Bray F, et al. GLOBOCAN 2008 v2.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10 [Internet]. Lyon (France):
International
Agency for Research on Cancer; 2010. Available at: http://globocan.iarc.fr. Accessed January 7, 2013.)

5. Epidemiology
• The age-standardized rate (ASR) of gastric malignancies among the
Jordanian population was 3.9 per 100,000 population, which puts
Jordan in the low-risk area.
• The ASR in Jordanian males was 4.9 and in females 2.9 per 100,000.
• Worldwide, it is believed that males are affected twice to 3 times
more often than females.

6. MALES VS FEMALES
Age-standardized (World) incidence and mortality rates in selected populations, 1978–2010. (A) male; (B) female. (Data from Curado MP,
Edwards B, Shin HR, et al. Cancer incidence in five continents, vol. IX. Lyon (France): IARC; 2007. IARC Scientific Publications No 160. Updated with
more recent data from cancer registries where available; and the World Health Organization. WHO mortality database. Available at: http://www.
dep.iarc.fr/WHOdb/WHOdb.htm. Accessed January 8, 2013.)

7. Epidemiology
Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin 2011; 61:69.

8. RISK FACTORS
•

9. Surgical Treatment for Gastric Cancer
• The standard operations are total gastrectomy and subtotal
gastrectomy
• nodal involvement or T2 to T4a tumors.
• Subtotal gastrectomy can be performed when a minimum of 2 to 5 cm
proximal cancer-free margin
• depending upon the depth of infiltration and the growth pattern of the
cancer
• Proximal gastrectomy can be performed for T1N0 proximal gastric
cancers when more than half of the distal stomach can be preserved
• and a pylorus-preserving gastrectomy can be performed for T1N0
cancers of the middle third of the stomach when the distal margin of
the tumor is at least 4 cm from the pylorus

10. Anatomical definition of lymph nodes and lymph node
regions
• The regional lymph nodes of the stomach are classified into
stations numbered 1 to 20, plus stations 110, 111 and 112.
• Some of lymph node stations numbered from 1 to 20 have been
subdivided in further subsets of nodes
• . Lymph node stations 1-12 and LN station 14v are defined as
regional stations; the remnant lymph node stations are considered
as distant stations and metastases to these nodes are classified as
M1.
• Lymph nodes No. 19, 10, 110 and 111 are considered as regional
lymph nodes in case of tumor invading the esophagus.

15. DEFINITIONS OF DIFFERENT LEVELS OF LYMPH
NODE DISSECTION
total
gastrectomy
the lymph nodes stations to be dissected in D1 No.1 to 7; D1+ includes
D1 stations plus stations No.8a, 9, and 11p, and D2 includes D1 stations
plus stations No.8a, 9, 10, 11p, 11d, and 12a. For tumors invading the
esophagus, D1+ includes N0. 110 and D2 includes Nos. 19,20,110 and 111.
distal
gastrectomy
the lymph nodes stations to be dissected in D1 lymphadenectomy are
stations No.1, 3, 4sb, 4d, 5, 6 and 7; D1+ includes D1 stations plus stations
No.8a, and 9, and D2 includes D1 stations plus stations No.8a, 9, 11p, and
12a.

16. Principles of radical operation for gastric cancer
i) Negative margin
ii) Extent of lymph node dissection
iii) Enbloc resection
Surgical Treatment for Gastric Cancer

17. Why comparing??
• laparoscopic surgery is currently preferred over open surgery.
• This includes surgical procedures such as cholecystectomy ,colon
cancer, and hysterectomy
• The reason for this preference of laparoscopic surgery over open
surgery is because of decreased pain, decreased blood loss, shorter
hospital stay, earlier postoperative recovery, better cosmetic (physical
appearance), and decreased costs

18. • the safety of the laparoscopic approach (for a procedure that has a high
complication rate) and cancer clearance after laparoscopic and
laparoscopy-assisted gastrectomy has to be ensured before the method
can be widely recommended
• There are concerns about cancer clearance, since port site metastases
(recurrence of cancer at the laparoscopic port site) have been reported
after many cancers.
• Another issue is the adequacy of cancer clearance in terms of resection
margins and the extent of lymph nodes removed with laparoscopy.
• Therefore, oncological safety (cancer clearance) is an important issue with
laparoscopic and laparoscopic-assisted gastrectomy

19. LG vs OG
• Surgical outcomes
• Adequacy of lymphadenectomy
• Technical challenges
• Learning curve
• Quality of life

20. Laparoscopic versus open gastrectomy for gastric cancer
(Review)

25. SURGICAL OUTCOMES
• Surg Endosc. 2019 Jan;33(1):33-45.
• Between March 2014 and August 2017,
• a total of 446 patients with cT2-4aN0-3M0 (AJCC 7th staging system) were
enrolled.
• 222 patients underwent LADG
• 220 patients underwent ODG
• No significant difference was observed regarding the overall postoperative
complication rate in two groups (LADG 13.1%, ODG 17.7%, P = 0.174).
• No operation-related death occurred in both arms.

28. Surgical outcomes
• Surg Endosc (2013) 27:2877–2885
• Feasibility of LG in AGC and evaluation of morbidity and
mortality
• 157 patients,20–80 years of age, cT2N0–cT4aN2, ASA =3 or less
• LG with D2 lymphadenectomy was safe and technically feasible for
the treatment of AGC, with acceptable rate of morbidity and
mortality(11.5% and 0.6%, respectively);

29. ONCOLOGIC EQUIVALENCY
• Surgery 2014;155:154-64.
• Compare the long-term outcomes of LG with open gastrectomy
(OG) for the treatment of gastric cancer.
• May 2003 and December 2009
• 1,874 patients, 816 were treated with OG and 1,058 with LG
• The number of harvested lymph nodes was similar between the
two Groups
• No difference in the recurrence-free survival between the 2 groups

30. ONCOLOGIC EQUIVALENCY
Number of retrieved lymph nodes according to tumor progression, operative
procedure, and extent of lymphadenectomy

31. ONCOLOGIC EQUIVALENCY
• Ann Surg 2005;241: 232–237
• 5-year clinical outcomes of LA and OG
• total of 59 patients - 29 patients (OG), 30 patients (LG).
• The mean number of resected lymph nodes was 33.4 in the OG group and 30.0 in
the LG

32. ONCOLOGIC EQUIVALENCY
Disease-free survival rates of LG and OG patients.

33. ONCOLOGIC EQUIVALENCY
• JAMA. 2019 May 28;321(20):1983-1992.
• Among 1056 patients,
• 1039 had surgery
• laparoscopic distal gastrectomy 519]
• open distal gastrectomy 520
• 999 completed the study.
• Three-year disease-free survival rate was 76.5% in the laparoscopic distal gastrectomy
• 77.8% in the open distal gastrectomy group,
• cumulative incidence of recurrence over the 3-year period (laparoscopic distal gastrectomy vs open distal
gastrectomy: 18.8% vs 16.5 did not significantly differ between laparoscopic distal gastrectomy and open
distal gastrectomy groups.

38. ONCOLOGIC EQUIVALENCY
• Surgery. 2019 Jun;165(6):1211-1216.
• Between January 2010 and June 2012, a total of 328 patients with preoperative clinical stage T2-
4aN0-3M0 gastric cancer were enrolled in the trial.
• 317 patients (161 in laparoscopy-assisted gastrectomy and 156 in open gastrectomy) eligible for
long-term analysis.
• The 5-year overall survival rate
• 49.0% in the laparoscopic group
• 50.7% in the open group
• 5-year disease-free survival rate
• 47.2% in the laparoscopic group
• 49.6% % in the open group
• no difference in the 5-year tumor recurrence rate between the 2 procedures.
• Laparoscopy-assisted gastrectomy can provide comparable long-term survival without an
increase in recurrence and metastasis in treating advanced gastric cancer.

41. LEARNING CURVE
 retrospectively reviewed and analysed the medical records of 80 patients with gastric
cancer who underwent TLDG with lymph node dissection from January 2016 to
December 2017.
 No significant difference was observed between the groups in various clinicopathologic
characteristics.
 divided the patients into four groups based on when they underwent TLDG:
 group A (cases 1–20), group B (cases 21–40), group C (cases 41–60), and group D (cases
61–80).
 Comparative analyses of clinical data, including clinicopathologic characteristics,
operative data, and postoperative course, were performed for these groups.

42. LEARNING CURVE
 Total operative time for group A (168.3 ±14.6 min) was significantly longer than for groups
B (152.5 ±10.5 min), C (154.2 ±11.6 min), and D (155.3 ±10.8 min), but there was no
significant difference between groups B, C, and D.
 Anastomosis time for group A (27.5 ±12.4 min) was significantly longer than for groups B
(15.3 ±4.6 min), C (16.6 ±5.7 min), and D (15.4 ±4.5 min),but there was no significant
difference between groups B, C, and D.
 Non-anastomosis time, estimated blood loss, retrieved lymph nodes, time to first flatus,
time to first oral intake, and postoperative hospital stay and complications showed no
difference between the four groups.
 An experience of approximately 20 cases of TLDG was required to complete the learning
curve.

43. Quality of life
July of 2003 to November of 2009
• 164 patients with ECG
• Randomly assigned either to LADG or ODG
• Complete the European Organization for Research and Treatment
of Cancer QLQ-C30 and QLQ-STO22 questionnaires
• Comparison of LADG to ODG in patients with early gastric cancer resulted in
improved QOL outcomes in the patients followed for up to 3 months in the
LADG group.

44. • Statistically significant differences were observed with a more favorable outcome noted
in the LADG group
• intraoperative blood loss (P < 0.001),
• total amount of analgesics used (P = 0.019),
• the size of the wound and QOL parameters of global health postoperative hospital
stay (P < 0.0001),
• and QOL parameters of global health (P < 0.0001
• Most of the scales on patient functioning including
• physical (P < 0.0005),
• role (P = 0.0011)
• , emotional (P < 0.0001),
• social (P < 0.0001),

45. • symptom scales such as
• fatigue (P < 0.0001),
• pain (P < 0.0001),
• appetite loss (P = 0.031),
• sleep disturbance (P = 0.003),
• dysphasia (P = 0.0024),
• gastro-esophageal reflux (P = 0.0127),
• dietary restriction (P = 0.0004),
• anxiety (P = 0.0036),
• dry mouth (P = 0.0007),

46. QUALITY OF LIFE

47. Thank you