By Victoria Stern

Reduced-port laparoscopic distal gastrectomy to treat early gastric cancer is a safe and feasible procedure that provides improved cosmesis and fewer port-related complications, according to a study presented at the recent International Congress of the European Association for Endoscopic Surgery (EAES) in Vienna.

The current standard of care for gastric cancer is open surgery, which includes subtotal gastrectomy or total gastrectomy with D2 lymph node dissection. “Laparoscopic gastrectomy is still classified as an investigational treatment because there is no level 1 evidence of long-term oncologic outcome even in early gastric cancer,” said Hyung-Ho Kim, MD, PhD, chairman of the Department of Surgery, Seoul National University Bundang Hospital, in Korea, and president of the Korean Laparoscopic Gastrointestinal Surgery Study Group, who was not involved in the current research.

In the United States, most gastric cancers are clinically advanced when diagnosed, but in Asian countries, many of these cancers are detected early. This means minimally invasive approaches could benefit patients in countries with robust early detection methods, said lead author Hiroyuki Kashiwagi, MD, Department of Surgery, Shonai Amarume Hospital, Yamagata, Japan.

Recently, laparoscopic approaches to treating early gastric cancer have started to gain momentum in East Asia, especially in Korea and Japan, with reports showing better early postoperative outcomes compared with open surgery. But only a handful of reports exist due to the technical difficulty and lack of tools designed specifically for such procedures. For instance, three studies detailing surgeons’ initial clinical experiences with single-incision laparoscopic distal gastrectomy for early gastric cancers have all required the use of one or two assistant ports (Surg Endosc 2011;25:2400-2404; Surg Laparosc Endosc Percutan Tech 2012;22:e214-e216; Surg Endosc 2012;26:1490-1494).

Now, the availability of multichannel ports, such as the single-incision laparoscopic surgery (SILS) port (Covidien, Japan), has made reduced-port laparoscopic distal gastrectomy more technically viable, allowing surgeons to insert up to three instruments through one port.

In the current study, Dr. Kashiwagi and his colleagues from the Department of Surgery, Shonai Amarume Hospital, Yamagata, Japan, performed a laparoscopic distal gastrectomy on 10 patients (six men, four women) diagnosed with early-stage gastric cancer between December 2010 and December 2012.

The team employed a dual-port method, using Covidien’s SILS port, a 5-mm flexible scope (Olympus, Japan) and surgical nylon with straight needles (Ethicon, Japan). Patients’ mean age was 68.1 years (range, 52-87 years) and body mass index was 21.4±4.5 kg/m2. Average operative time was 266.9±38.3 minutes and blood loss was 37.8±56.8 mL. Patients recovered well and experienced no complications postsurgery. All patients could tolerate soft meals on postoperative day 1 and had an average hospital length of stay (LOS) of eight days.

Additionally, the authors reported no differences between the current SILS dual-port approach and the laparoscopic multiport method they performed on nine patients between 2008 and 2010, in terms of mean operative time (266.9±38.3 vs. 255.3±68.5 min., respectively), blood loss (37.8±56.8 vs. 55.4±57.1 mL, respectively) and retrieved lymph nodes (16.1±8.9 vs. 14.9±7.2, respectively). Postoperative hospital LOS, however, was significantly longer in the conventional multiport group (17.3±7.4 vs. 8.1±1.5 days; P<0.0001), and three patients in the conventional multiport group experienced complications (one case of postoperative pneumonia and two cases of gastric stasis). There were no complications in the dual-port group.

This study was nominated for the Olympus EAES Award for best oral presentation on single-port surgery.

Although the benefits of SILS compared with conventional laparoscopic surgery have not been established through a head-to-head analysis, single-site surgery does show promise. In addition to cosmetic benefits, Dr. Kashiwagi concluded that a single-port approach to early gastric cancers may result in less postoperative pain and a shorter hospital LOS as well as a reduced chance of tissue trauma and complications associated with creating multiple ports, such as organ damage, bleeding, wound infection and hernias.

Recently, Dr. Kim and his colleagues revealed the results of their pure SILS approach to early gastric cancers, presenting their initial findings at the annual International Gastric Cancer Congress in Italy. Dr. Kim’s team reported similar operative times and morbidity as well as better short-term outcomes—including reduced postoperative pain, blood loss, and improved cosmesis—for single-incision distal gastrectomy compared with the conventional laparoscopic approach.

According to Dr. Kashiwagi, more research is needed to make reduced-port surgery a standard approach in countries with high rates of early detection of gastric cancers. “We need to perform larger studies to confirm the advantages of this operation,” he said.

Dr. Kim agreed, adding that advancing the single-port technique will involve further development of smart, articulated instruments and perhaps also robotic technology.

Although still early, Dr. Kashiwagi believes that eventually “reduced-port surgery will become a standard therapy for early-stage gastric cancer, although not for advanced cancer.”

Drs. Kashiwagi and Kim reported no relevant conflicts of interest.