Laparoscopic gastrectomy for cancer

INTRODUCTION — Gastrectomy for adenocarcinoma via an open abdominal approach (OG) has been performed since the 1920s. Laparoscopic gastrectomy (LG) was first described in Japan in 1994, where a distal gastrectomy with Billroth I gastroduodenostomy reconstruction was performed for an early-stage gastric cancer [1]. Since then, surgical experience with LG has been increasing, particularly in Eastern countries such as Japan, Korea, and China, where gastric adenocarcinoma is more prevalent.

The indications, patient selection, surgical techniques, postoperative care, and outcomes of LG for cancer are discussed in this topic. OG and LG for benign diseases (eg, peptic ulcer) or weight loss are discussed in other topics. (See "Surgical management of peptic ulcer disease" and "Partial gastrectomy and gastrointestinal reconstruction" and "Total gastrectomy and gastrointestinal reconstruction" and "Bariatric procedures for the management of severe obesity: Descriptions" and "Surgical management of invasive gastric cancer".)

EASTERN VERSUS WESTERN EXPERIENCE

Eastern experience — LG is a well-established technique for treating gastric cancer in Eastern countries. According to national surveys, LG accounted for approximately 25 percent of all gastric surgeries performed for cancer in Japan and South Korea as early as 2009 [2]. The efficacy of LG has been demonstrated for both early and locally advanced gastric cancers in Eastern countries [3].

Early gastric cancer — Early gastric cancer is defined as invasive gastric cancer that invades no more deeply than the submucosa, regardless of lymph node metastasis (T1, any N, M0) (table 1). Early gastric cancer is of particular importance to patients in East Asia, where it accounts for 25 to 50 percent of all gastric cancers diagnosed because of screening programs. (See "Early gastric cancer: Epidemiology, clinical manifestations, diagnosis, and staging".)

An early Japanese study involving 1294 patients undergoing LG (91.5 percent distal gastrectomy) for gastric cancer from 1994 to 2003 showed mortality and morbidity rates of 0 and 14.8 percent and a recurrence rate of 0.6 percent at a median follow-up of three years [4]. The five-year disease-free survival rate was 99.8 percent for stage IA disease, 98.7 percent for stage IB disease, and 85.7 percent for stage II disease.

A subsequent Japanese study (LOC-1) compared the outcomes of 3630 patients with early gastric cancer treated with LG or open gastrectomy (OG) from 2006 to 2012 [5]. By propensity score-matched analysis, there was no difference in five-year overall survival (97.1 percent LG versus 96.3 percent OG), three-year recurrence-free survival (97.7 versus 97.4 percent), or local recurrence rate (2.3 versus 2.4 percent).

In a Korean trial (KLASS-1), over 1400 patients with stage I early gastric cancer were randomly assigned to either open or laparoscopic distal gastrectomy between 2006 and 2010 [6]. The overall complication rate (13 versus 20 percent) and wound complication rate (3.6 versus 7 percent) were lower in the LG group. Major intra-abdominal complication and perioperative mortality rates were similar between the two groups. At five years, the overall (94.2 percent LG and 93.3 percent OG) and cancer-specific survival rates (97.1 percent LG and 97.2 percent OG) were not different between the two groups either [7].

Another large trial from Japan (JCOG0912) randomly assigned 921 patients with clinical stage I gastric cancer in the middle or lower third of the stomach to either LG or OG from 2010 to 2013 [8]. Compared with OG, LG required longer operative time but had less blood loss. Otherwise, there was no difference in short-term morbidity and mortality rates. The five-year relapse-free survival was 94 percent (95% CI 91.4-95.9) in the OG group and 95.1 percent (95% CI 92.7-96.8) in the LG group [9].

With respect to proximal gastric cancers, an ongoing multicenter prospective Korean trial (KLASS-03) has established the feasibility and safety of laparoscopic total gastrectomy in early-stage gastric cancers [10].

Similarly, in a multicenter trial from China (CLASS02), in which 214 patients with clinical stage I gastric cancer underwent laparoscopic or open total gastrectomy, the perioperative morbidity and mortality rates were not significantly different between the two groups (laparoscopic 18.1 and 1 percent; open 17.4 and 0 percent) [11]. Laparoscopic total gastrectomy was associated with longer operative time but less blood loss. Further follow-up is needed to establish the long-term oncologic safety of the laparoscopic approach in proximal gastric cancers.

Locally advanced gastric cancer — Locally advanced gastric cancer invades deeper than the submucosa, regardless of lymph node metastasis (≥T2, any N, M0) (table 1). As their experience with LG for early gastric cancer grew, Eastern surgeons began to treat locally advanced gastric cancers with LG as well. In particular, the paucity of early gastric cancer and abundance of locally advanced gastric cancer in China (relative to Japan and Korea) prompted surgeons there to pursue LG for locally advanced gastric cancers [12].

In a retrospective study of over 1100 patients in China who underwent LG for stage I, II, or III gastric cancer between 2003 and 2009, perioperative morbidity and mortality rates were 10 and 0.1 percent, overall and locoregional recurrence rates were 16.7 and 2.3 percent, and survival at a median follow-up of 12 months varied between 60 and 90 percent, depending on disease stage [13].

In a Chinese trial (CLASS-01) conducted from 2012 to 2014, over 1000 patients with locally advanced gastric cancer (T2-4, N0-3, M0) were randomly assigned to either LG or OG, both including a D2 lymphadenectomy [14]. LG and OG resulted in similar perioperative morbidity (15 versus 13 percent) and mortality rates (0.4 versus 0 percent) as well as compliance rates of D2 lymphadenectomy (both >99 percent). At three years, LG and OG resulted in similar overall survival (83 versus 85 percent), disease-free survival (77 versus 78 percent), and cumulative recurrence rates (19 versus 17 percent) [15]. At five years, LG and OG again resulted in similar overall survival (73 versus 76 percent) [16]. The CLASS-01 study demonstrated that when performed by experienced surgeons, laparoscopic distal gastrectomy with D2 lymphadenectomy is safe and effective for clinically staged locally advanced gastric cancers. However, about one-third of patients were overstaged and had pathologic stage I tumors. None of the patients received neoadjuvant therapy, contrary to what is typically recommended in Western patients. Additionally, since most Western patients predominantly require proximal as opposed to distal gastrectomy, these results may be limited in applicability to a Western population.

Similarly, in a Korean trial (KLASS-02-RCT) conducted from 2011 to 2015, over 1000 patients with cT2-4a, N0-1 gastric adenocarcinoma were randomly assigned to either LG or OG, both with D2 lymphadenectomy [17]. LG resulted in a lower 30 day morbidity rate (16.6 versus 24.1 percent), lower patient-reported pain score, less postoperative analgesic use, earlier passage of flatus, and shorter hospital stay (8.1 versus 9.3 days) than OG. The mean number of lymph nodes retrieved and 90 day mortality rate were comparable between the two groups. At three years, relapse-free survivals were also comparable between the two groups (80.3 percent LG, 81.3 percent OG) [18]. At five years, relapse-free survivals remained comparable (79.5 percent LG, 81.1 percent OG) and late complications (eg, intestinal obstruction) were less frequent after LG (6.5 percent LG, 11 percent OG) [19].

One other trial, JLSSG0901 from Japan [20], is currently ongoing to evaluate the efficacy of LG for locally advanced gastric cancer.

Western experience — Compared with Eastern countries, LG is underutilized in Western countries. An analysis of the University Health System Consortium database demonstrated that 89.5, 8.2, and 2.3 percent of over 9500 gastrectomies were performed open, laparoscopically, and robotically from 2008 to 2013 [21]. Another analysis of the United States National Cancer Database showed that 73.4, 23.1, and 3.5 percent of over 6400 gastrectomies for cancer were performed open, laparoscopically, and robotically between 2010 and 2012 [22]. Limited by a lower prevalence of gastric cancer, fewer studies and only one randomized trial of LG have been conducted in Western countries.

In the Dutch LOGICA trial, 227 patients with cT1-4a, N0-3b, M0 gastric cancer underwent OG or LG. LG resulted in less blood loss than open surgery but had a longer operative time. Otherwise, OG and LG did not differ in postoperative complication rate, in-hospital mortality rate, 30 day readmission rate, R0 resection rate, median lymph node yield, one-year overall survival rate, and global health-related quality of life up to one year postoperatively [23].

In a study of 87 LGs and 87 matched OGs performed for stage I, II, or III gastric cancer from 2005 to 2013 at the Memorial Sloan Kettering Cancer Center, LG was associated with a longer operative time but shorter length of stay and fewer early and late complications [24].

The same study using the National Cancer Database mentioned above showed LG to be associated with a shorter length of hospital stay (by one day), a greater lymph node yield (odds ratio 1.16 of having ≥15 nodes), and comparable negative margin and mortality rates compared with OG [22].

Another European trial, Surgical Technique, Open versus Minimally Invasive Gastrectomy after Chemotherapy (STOMACH), randomly assigned 96 patients to either minimally invasive versus open total gastrectomy after receiving neoadjuvant chemotherapy from 2015 to 2018 [25]. There was no difference in operative or postoperative outcomes, and similar one-year survival was seen between the two groups. This trial suggested the oncologically noninferior outcomes of a minimally invasive approach, but three-year results are pending.

East versus West — Clinicopathological presentations of gastric cancer are known to vary widely between Eastern and Western countries. In a study comparing all patients undergoing curative resections (R0) for gastric cancer at two high-volume hospitals from the United States (US; 711 patients) and Korea (1646 patients), age and body mass index were significantly higher in US patients [26]. The location of tumors was more often proximal in the US (39 versus 9 percent) and distal in Korea (54 versus 33 percent). Korean patients had more early-stage tumors (42 versus 28 percent stage IA) and a greater lymph node yield (97 versus 79 percent, ≥15 lymph nodes). With the exception of lymph node yield, all the other factors were potentially biased against US patients, which may at least partially explain why Eastern patients have a better survival rate than Western patients.

There is also evidence that Eastern patients may have superior survival compared with Western patients on a stage-for-stage basis [26,27]. However, it remains controversial whether the difference in survival is due to tumor biology; patient, genetic, and environmental factors; or treatment. There is no suggestion, however, that the survival is influenced by technical aspects such as the use of LG.

PATIENT SELECTION — Studies cited above suggest that LG is safe, feasible, and oncologically sound when performed by experienced surgeons in both Eastern and Western countries, although long-term randomized data have not yet been accrued. Whether to pursue LG or open gastrectomy (OG) depends on the following provider and patient factors.

Provider factors — LG is a technically demanding procedure that requires advanced skills and teamwork. The surgeon performing LG must be experienced with both complex gastrointestinal and advanced minimally invasive procedures and be supported by staff and hospital resources of equal competence.

Surgeon experience — LG is a complex minimally invasive procedure. The learning curve associated with becoming proficient in performing LG, particularly the D2 lymphadenectomy and reconstruction portions of the operation, can be quite steep.

Studies from Eastern countries estimated that surgeons would require at least between 40 and 60, and possibly over 90, cases of laparoscopic distal gastrectomy [28-30], or over 100 cases of laparoscopic total gastrectomy [31], to become proficient. In at least one study, performing fewer than 45 cases of laparoscopic total gastrectomy was associated with higher morbidity [32]. There have been no studies on the learning curve of LG from Western countries.

Hospital resources — An experienced surgeon needs to be supported by an operating room and anesthesia staff that is equally facile with handling advanced minimally invasive surgery. In the event that a complication occurs, additional support from critical care intensivists, therapeutic gastroenterologists, and interventional radiologists may be required. Expert physical therapy and nutritional support services are also imperative to good outcomes as many patients with gastric cancer come to surgery in frail or debilitated conditions, especially after receiving neoadjuvant chemotherapy.

Patient factors — Patient-related factors, such as body habitus, comorbidities, and cancer stage, can also influence the choice of LG versus OG. Patients who have early gastric cancer and those who are free from significant cardiopulmonary comorbidities, obesity, and previous upper abdominal surgery are the best candidates for LG.

Comorbidities — Patients with severe obstructive pulmonary disease (COPD) or cardiac disease may not tolerate the prolonged pneumoperitoneum that is often required for LG. Such patients should undergo OG instead.

Obesity — Obesity (body mass index ≥30 kg/m²), or increased visceral adiposity, can make LG with D2 lymphadenectomy technically challenging. Studies from Eastern countries found that LG in patients with obesity may require longer operative times than OG, although lymph node yield, postoperative recovery, and complication rate were not different [33-35].

Previous abdominal surgery — Previous abdominal surgery may make LG technically challenging due to the presence of adhesions or altered anatomy. However, this factor alone should not preclude LG [36].

Disease extent — Patients with early-stage disease without local invasion into surrounding structures or bulky lymphadenopathy are optimal candidates for surgeons to initiate an LG experience. Patients with locally advanced tumors that downstage after neoadjuvant therapy and those who undergo prophylactic total gastrectomy for CDH1 or other mutations may also be candidates for LG. (See "Surgical management of hereditary diffuse gastric cancer".)

However, in the United States and other Western countries, patients often present in advanced stages of gastric cancer. Larger tumors and locally advanced tumors with clear invasion into adjacent organs are best resected with OG, which offers tactile feedback that is lacking in LG.

SURGICAL TECHNIQUES

Laparoscopic total gastrectomy — Laparoscopic total gastrectomy is riskier and technically more demanding than laparoscopic distal gastrectomy because of the requirement of an esophagojejunostomy.

The patient is placed in a supine or modified lithotomy position, depending upon surgeon preference. The author favors a five-port technique that involves three 12 mm ports and two 5 mm ports. Typically, the central 12 mm camera port is positioned at the level of the umbilicus or just above, depending upon the length of the torso (figure 1). The patient is placed into a slight reverse Trendelenburg (head up) position.

Assessment of the peritoneal cavity for micrometastatic disease is performed upon establishing pneumoperitoneum. If metastatic disease is identified and confirmed with frozen section biopsy, resection is aborted. (See "Diagnostic staging laparoscopy for digestive system cancers", section on 'Esophagogastric junction and gastric cancer'.)

The left lateral segment of the liver can then be retracted using one of the following techniques:

●With a Diamond-Flex- or Nathanson-type retractor placed via a stab incision

●With a gauze that is retracted by a suture clipped to the pars flaccida of the gastrohepatic ligament and brought out the anterior abdominal wall

●With a silicone disc (as described by Japanese surgeons) [37,38]

The gastrocolic ligament is then divided with LigaSure or a Harmonic scalpel. Dissection proceeds cephalad along the greater curvature of the stomach until all of the short gastric vessels have been divided, the fundus of the stomach is fully mobilized, and the left diaphragmatic crus is identified. Dissection then proceeds caudally along the distal aspect of the stomach toward the pylorus. The right gastroepiploic artery and vein are stripped of lymphatic tissue and divided either between clips or with a vascular stapler (figure 2). This allows for skeletonization of the inferior aspect of the pylorus. The posterior wall of the stomach should be dissected off the anterior aspect of the pancreas (picture 1). The gastroduodenal artery can be identified posterior to the pylorus, along the duodenum.

The gastrohepatic ligament is then divided to facilitate dissection along the lesser curvature. The right gastric artery is divided at its insertion into the pylorus (figure 2). The superior aspect of the pylorus is skeletonized and dissected free until it can be elevated off the pancreas; this may necessitate mobilization of the duodenal bulb superiorly from the retroperitoneum.

The duodenum just distal to the pylorus is transected with an Endo GIA stapler. Retraction of the stomach inferiorly exposes the lesser sac space. The common hepatic artery is identified. The lymph nodes overlying the common hepatic artery are dissected free; this dissection proceeds distally until the takeoff of the gastroduodenal artery. With anterior elevation of the stomach, the left gastric artery is identified. The left gastric artery and vein are cleared of lymphatic tissue, and the vessels are divided close to the celiac axis. Similarly, the origin of the splenic artery is identified and cleared of lymphatic tissue.

Once lymphadenectomy has been completed in the lesser sac space, the dissection proceeds along the lesser curvature cephalad toward the phrenoesophageal ligament. The right diaphragmatic crus is identified. The phrenoesophageal ligament is divided, and the esophagus is mobilized circumferentially. The esophagus just proximal to the gastroesophageal junction is transected with an Endo GIA stapler (picture 2), and the entire stomach is placed into a specimen bag and retrieved. The author favors performing frozen section analysis of the proximal margin. An omentectomy is also performed prior to reconstruction of the alimentary tract.

The jejunum is transected 20 to 30 cm distal to the ligament of Treitz. The distal end should be able to reach the esophageal stump without tension, in an antecolic fashion. Esophagojejunostomy reconstruction can be performed either handsewn or with a circular EEA stapler. The author utilizes an EEA stapler with an anvil that is passed transorally (the OrVil device). The staple line to the distal jejunal stump is removed to allow insertion of the stapler handle. After the spike of the stapler is driven through the jejunal bowel wall, it is connected with the anvil and the stapler fired to create a circular anastomosis (picture 3 and picture 4). The stapler handle is removed, and the jejunotomy is closed with an additional firing of the Endo GIA stapler, creating a small jejunal pouch distal to the anastomosis (figure 3 and figure 4). A 50 to 60 cm Roux limb is measured, and a side-to-side jejunojejunostomy is created with an Endo GIA stapler. Distal to that, a feeding jejunostomy tube is often placed, in accordance with surgeon preference.

Laparoscopic distal gastrectomy — A laparoscopic distal gastrectomy is performed with similar ports and liver retraction methods to those of a laparoscopic total gastrectomy. Depending on the location of the tumor, it may not be necessary to completely mobilize the fundus or divide the left gastric artery. The stomach is transected with the aim of achieving a 5 cm gross margin in the proximal stomach. After a similar lymphadenectomy and omentectomy have been performed, the gastrointestinal tract is reconstructed with a Billroth II gastrojejunostomy or Roux-en-Y gastrojejunostomy (figure 5). Feeding tubes are typically not required for distal gastrectomy.

Step-by-step guidance for a robotic distal subtotal gastrectomy with D2 lymphadenectomy procedures has been created [39]. It contains short video clips of 20 key steps of a standardized procedure and can be displayed on the robotic console intraoperatively in real time for mentoring purposes.

Laparoscopic pylorus preserving gastrectomy — Pylorus-preserving gastrectomy (PPG) was originally used for peptic ulcer disease but has since been adapted in East Asia to treat early gastric cancer located in the middle third of the stomach, >5 cm from the pylorus. It is oncologically safe as the risk of metastasis to the suprapyloric lymph nodes is very low [40].

In the KLASS-4 trial, patients who underwent laparoscopic PPG and laparoscopic distal gastrectomy had similar short-term outcomes [41]. A separate nonrandomized Korean study analyzed 288 patients undergoing gastrectomy for early gastric cancer from 2013 to 2016; 145 underwent PPG. Compared with other resection types, PPG was associated with narrower surgical margins and fewer total numbers of resected lymph nodes but similar incidences of delayed gastric emptying and similar three-year recurrence-free survivals. The PPG group also showed a lower decrease in body weight and body mass index at 6 and 12 months [42].

Laparoscopic proximal gastrectomy — First described in 1995 [43], laparoscopic proximal gastrectomy is an alternative to total gastrectomy for patients with proximal gastric cancer that may offer them better long-term nutritional outcomes.

To mitigate potentially significant postoperative reflux that can occur following proximal gastrectomy, many reconstruction techniques have been devised, including esophagogastrostomy, esophagogastrostomy with gastric tube creation, esophagogastrostomy with fundoplication, esophagojejunostomy with jejunal interposition, and esophagojejunostomy with double tract reconstruction [44].

Based on limited series, patient nutrition status does seem to improve with proximal gastrectomy compared with total gastrectomy, while short-term surgical and oncologic outcomes appear similar [45,46]. Further studies with more patients and longer follow-up are needed to determine the role of proximal gastrectomy in the treatment of proximal gastric cancer.

POSTOPERATIVE CARE — Following LG, patients are admitted to the regular surgical floor unless more intensive monitoring is required. Enhanced recovery programs for minimally invasive procedures should be followed, with emphasis on early mobilization and preference for non-narcotic analgesia [47,48]. Compared with conventional care, enhanced recovery programs were associated with earlier time to ambulation and oral intake, shorter length of hospital stay, and comparable morbidity and mortality [47].

It is the author's practice to routinely use prophylactic nasogastric tube decompression following total gastrectomy but not following distal gastrectomy. In total gastrectomy, the nasogastric tube is placed across the esophagojejunostomy as a transanastomotic "stent"; the tube is typically removed following a negative swallow study performed on postoperative day 4 or 5. A swallow test is not routinely performed in patients undergoing distal gastrectomy.

Diet is typically advanced as tolerated from postoperative day 1 or 2 following distal gastrectomy and following a negative swallow study for those undergoing total gastrectomy. Because oral intake is often not enough to sustain hydration and nutrition after a total gastrectomy, the author initiates trickle jejunal tube feeding 24 hours after surgery with slow advancement until the combination of oral intake and jejunal tube feeding becomes sufficient to sustain hydration and nutrition.

Once the patient is taking in sufficient oral intake to maintain body weight, the jejunal feeding tube can be removed in the office. By contrast, surgeons in the East largely avoid using feeding tubes, even in total gastrectomy patients.

OUTCOMES

In Eastern countries, LG has been compared with open gastrectomy (OG) in multiple randomized trials (see 'Eastern experience' above). A 2016 systematic review and meta-analysis of 14 such trials including over 2000 patients concluded that [49]:

●LG resulted in less blood loss; shorter time to first flatus, first walking, and first oral intake; reduced frequency of analgesic administration; shorter hospital stay; and reduced overall postoperative morbidity.

●There was no difference in number of retrieved lymph nodes, mortality, recurrence, long-term overall survival, and disease-free survival between LG and OG.

●LG was associated with higher patient satisfaction and quality of life.

A 2022 systematic review and meta-analysis of 22 randomized trials (20 of which were from Eastern countries) reached the same conclusions [50].

A prospective study from Korea with an emphasis on quality of life found LG to be superior to OG [51]. Specifically, patients reported better global health and functional quality of life; less appetite loss, pain, and reflux; fewer emotional problems; and improved body image at three months after LG compared with after OG.

Continued follow-up of the same group of patients, however, showed that the differences in quality of life mostly disappeared by approximately 24 months after surgery, with two exceptions: the dysphagia symptom score remained higher in the OG group, and the dyspnea symptom score remained higher in the LG group [52].

Using propensity score matching, a study of over 17,000 patients from the National Cancer Database (NCDB) between 2010 and 2015 found that minimally invasive gastrectomy was associated with improved five-year survival (51.9 versus 47.7 percent, p<0.0001) compared with open gastrectomy [53]. There was no difference between laparoscopic and robotic approaches.

MINIMALLY INVASIVE ALTERNATIVES

Robotic surgery — Since the early 2000s, robotic gastric surgery has emerged as an alternative minimally invasive technique to LG. However, in Western countries such as the United States and countries in Europe, robotic gastric surgery remains an emerging rather than established technology.

Compared with conventional LG, robotic gastric surgery has the advantages of three-dimensional high-definition visualization, wristed and articulated movements, and improved ergonomics, with the surgeon able to sit during the operation. The cost of the robotic platform is higher than with laparoscopy, and operative times are typically longer.

The robotic platform also permits near-infrared fluorescent visualization, which can be used to guide lymph node dissection [54,55]. In small studies, this technique has yielded greater numbers of lymph nodes overall or at certain lymph node stations. However, it is unclear if a more extended lymph node dissection will translate into better cancer-specific survival.

Robotic gastric surgery has been compared with LG in both Eastern and Western series [22,56-60]. In a systematic review and meta-analysis of 12 studies including over 3500 patients, robotic gastric surgery was associated with less blood loss, less time to first flatus, and greater lymph node yield than conventional LG [61]. Robotic gastric resection was also associated with shorter hospital stay but longer operative time. Robotic gastric resection and LG had similar postoperative morbidity, mortality, and conversion rates.

A Chinese trial compared robotic distal gastrectomy (RDG) with laparoscopic distal gastrectomy (LDG) in 283 patients with gastric cancer [62]. Although total surgical duration was longer with RDG, intraoperative blood loss was significantly less. Postoperative length of stay was similar between the two groups. Although the total number of examined lymph nodes was similar between the groups, dissection of certain lymph node stations was improved with RDG. Patients undergoing RDG also seemed to be able to initiate adjuvant chemotherapy earlier than those in the LDG group.

A Japanese single-institution phase III trial randomly assigned 241 patients with resectable gastric cancer to either laparoscopic (LG) or robotic gastrectomy (RG) [63]. The overall incidence of postoperative complications of grade II or higher was significantly higher in the LG group than the RG group (19.7 versus 8.8 percent), and so was the complication rate of grade IIIa or higher (16.2 versus 5.3 percent). However, the intra-abdominal infectious complication rates were similar between LG and RG.

Endoscopic resection — Endoscopic resection and combined endoscopic-laparoscopic resection are other minimally invasive options for treating early-stage gastric cancer. (See "Overview of endoscopic resection of gastrointestinal tumors".)

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been widely used in Eastern countries to treat early gastric cancer. A common indication is for well-differentiated, nonulcerated mucosal lesions <2 cm [64]. (See "Overview of endoscopic resection of gastrointestinal tumors", section on 'Gastric cancer'.)

Endoscopic resection is highly operator dependent in achieving negative margins with an adequate resection. Although more liberal uses of endoscopic resection have been advocated [65,66], studies with longer follow-up, particularly in the United States and Europe, are required before new indications become widely accepted.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gastric cancer" and "Society guideline links: Laparoscopic and robotic surgery" and "Society guideline links: Gastric surgery for cancer".)

SUMMARY AND RECOMMENDATIONS

●Requirements for laparoscopic gastrectomy – The surgeon performing laparoscopic gastrectomy (LG) must be experienced with both complex gastrointestinal and advanced minimally invasive procedures and be supported by staff and hospital resources of equal competence. Patients with early gastric cancer who are free of significant cardiopulmonary comorbidities, obesity, and previous upper abdominal surgery are the best candidates for LG. (See 'Patient selection' above.)

●Laparoscopic total gastrectomy – Laparoscopic total gastrectomy requires port placement, liver retraction, dissection along the greater and lesser curvature of the stomach, lymphadenectomy, vascular division, duodenal and esophageal transection, and esophagojejunostomy reconstruction. (See 'Laparoscopic total gastrectomy' above.)

●Laparoscopic distal gastrectomy – Laparoscopic distal gastrectomy follows the same general steps of a total gastrectomy but may not require full mobilization of the fundus or division of the left gastric artery depending on the location of the tumor. A gross margin of 5 cm in the proximal stomach is required. Reconstruction is typically by a Billroth II gastrojejunostomy or Roux-en-Y gastrojejunostomy. (See 'Laparoscopic distal gastrectomy' above.)

●Postoperative care – Enhanced recovery programs for minimally invasive procedures should be followed, with emphasis on early mobilization and preference for non-narcotic analgesia. In the author's practice, nasogastric tube decompression across the anastomosis and jejunal tube feeding are routinely used after total but not distal gastrectomy. (See 'Postoperative care' above.)

●Outcomes – Compared with open gastrectomy (OG), LG has superior or equal short-term patient outcomes and comparable long-term oncologic outcomes. Patients undergoing LG also report a better quality of life in the early postoperative period, but the difference disappears after two years. (See 'Outcomes' above.)

●Minimally invasive alternatives to laparoscopic gastrectomy – Alternative minimally invasive techniques of treating gastric cancer include robotic gastric resection and endoscopic resection. (See 'Minimally invasive alternatives' above.)