The long-term efficacy of laparoscopic surgery in early and advanced gastric cancer

Laparoscopic surgery for the treatment of gastrointestinal cancer has rapidly evolved over the last decade. Although critical analysis of the short-term outcomes of laparoscopic gastrectomy has provided evidence for the safety of this minimally invasive approach, little long-term survival data, particularly for patients with advanced stage II and III gastric cancer, are available [1]. This lack of evidence increases the skepticism about the ability of laparoscopic gastrectomy for advanced gastric cancer to control cancer cell dissemination and prevent recurrence. This gap between expectations of and concerns about the long-term impact of laparoscopic gastrectomy on gastric cancer patients has been bridged by the study of Pak et al. [2] reported in the January issue of Surgical Endoscopy. The authors have analyzed the results of 714 consecutive patients with gastric cancer who underwent laparoscopic gastrectomy in their institution between May 2003 and December 2009. After a median follow-up of 46 months, recurrence was observed in 26 patients (3.7 %), with the secondary tumor located in the peritoneum in seven patients), locoregional in six patients, in distant organs with hematogenous spread in five patients, and other less frequent failures. The 5-year recurrence-free survival rates according to the TNM staging system categories were 95.8 % in stage I patients, 83.4 % in stage II patients, and 46.4 % in stage III patients. This study provides excellent results, similar to those reported by the randomized controlled trials (RCTs) with open D2 gastrectomy for stage II–III disease by Sasako et al. [3]. However, what is the reality from a Western point of view? In contrast to the excellent expertise in laparoscopic gastrectomy of Korean surgeons, a sample size as large as 714 patients treated within 7 years is unrealistic in Western countries, even in specialized hospitals. This lack of high-volume surgeons, which is a predictive factor for safe and effective laparoscopic surgery, raises attention. Indeed, although laparoscopic resection tends to be routinely performed for colorectal cancer, laparoscopic D2 gastrectomy for advanced tumors still remains a grand challenge for Western surgeons [4–11]. Such an approach is less familiar to Western surgeons and can be associated with the reports of increased postoperative complications and mortality. While awaiting the results of confirmatory RCTs for laparoscopic D2 gastrectomy for advanced resectable gastric cancer, biomedical research is focused on novel drugs developed based on the concept of signaling transduction interaction networks. In the era of systems science and biological circuits, there is emerging research based on the latest genome sequencing technology and living-cells networks-based imaging technologies. These advances together with substantial progress in computational systems biology, synthetic biology engineered-based reconstruction of signaling circuits, and mathematical models now shape new horizons in the discovery of innovative biomarkertargeted drug complexes for personalized treatment of cancer patients [12–32].