Laparoscopic versus open gastrectomy for gastric cancer

Abstract

General introduction and thesis outline Gastric and esophageal cancer are the third and sixth more common causes of cancer-related death worldwide. In addition, the incidence of adenocarcinoma of the proximal stomach, gastroesophageal junction (GEJ) and distal esophagus is increasing, especially in Western populations. Unfortunately, only slightly over 50% of patients are diagnosed with potentially curable disease. Treatment with curative intent generally consists of surgical resection and chemo(radio)therapy. However, this treatment can lead to major morbidity and less than 40% of patients undergoing this treatment are cured. In addition, for the majority of patients, the current optimal treatment is relatively similar. Ultimately, to improve outcomes, treatment should be further tailored to the individual patient. The first aim of this thesis was to compare the two most important approaches of curative surgery for the relatively common gastric adenocarcinoma: laparoscopic versus open gastrectomy (part I). The second aim of this thesis was to evaluate treatment for less common subtypes of gastroesophageal cancer and treatment in patients at high risk for postoperative complications, to work towards a more personalized treatment of gastroesophageal cancer (part II).

Conclusion Results from the multicenter randomized LOGICA-trial, performed in a Western population with mainly locally advanced gastric adenocarcinoma, demonstrated that postoperative complications, postoperative recovery, quality of life and oncological efficacy were comparable between laparoscopic and open gastrectomy. In laparoscopic gastrectomy, adequate pain control was achieved, generally without epidural analgesia. In addition, fewer patients used oral opioids at discharge, compared to the open gastrectomy. Differences in costs were limited between both treatments, though they might slightly favor open gastrectomy. These results support centers to choose, based upon their own preference, whether or not to (de)implement laparoscopic gastrectomy as an alternative to open gastrectomy. Three nationwide retrospective studies were performed in patients with less common subtypes of gastroesophageal cancer: diffuse type carcinoma (including SRCC), (MA)NEC and gastroesophageal cancer with hepatic or pulmonary oligometastases. The results provide insights that can help guide treatment decisions at multidisciplinary tumor boards. Two new clinical trials were designed and initiated as part of this thesis. The CARDIA-trial includes patients with Siewert type 2 GEJ cancer and the ISCON-trial includes patients with esophageal cancer selected on preoperative CT-scan to be at high risk for postoperative morbidity. Once completed, the results will help guide and further improve surgical treatment strategies for these patients.