Locally Advanced Gastric Cancer: The Edge of the Minimally Invasive Approach

Data on minimally invasive approaches for locally advanced gastric cancer were provided by KLASS-02 and CLASS-01: there are no differences between laparoscopic and open distal gastrectomy in 3-year overall and disease-free survival. Some concern still remains, however, regarding the applicability of such data in the West, since both these Eastern trials excluded patients receiving preoperative chemotherapy and cases with extensive/bulky nodes, which represent most Western patients with locally advanced gastric cancer. Concerns exist on laparoscopic total gastrectomy due to the technical issue of esophagojejunal anastomosis. The European multicenter STOMACH trial apparently resolved some of these doubts. In a post neoadjuvant setting, laparoscopic total gastrectomy and open surgery provided similar results in terms of retrieved nodes, as well as similar postoperative complication and 1-year survival rates. Late follow-up will provide the most crucial data; however, sample size was calculated for lymph node dissection, not for long-term survival. Moreover, we should consider that total gastrectomy with D2 lymphadenectomy might not be enough to treat locally advanced gastric cancer: splenectomy, bursectomy, D3 lymphadenectomy could be also indicated. Based on these considerations, providing evidence on the role of laparoscopic gastrectomy for locally advanced cases cannot be reduced to “OK, it is feasible”.