Distal gastrectomy: the evidence-a narrative overview

Abstract

Objective: To perform a narrative overview of the distal laparoscopic gastrectomy in the last 30 years. Background: Since the first minimally invasive distal gastrectomy performed by Kitano in 1991, there has been an enormous development in the minimally invasive surgery, especially after the year 2000. The first well-structured studies were performed in Japan and Korea, particularly regarding early tumors. In the East, during the early years, several European papers especially in Italy showed good results in small series, at that time also including advanced tumors, with survival rates equal to those of open surgery. In the initial experience, the laparoscopic operative time was superior to the gastrectomy performed by laparotomy. As the years went by, the better training and experience, led to a shorter surgical time, with the same lymph node number, faster time to the first flatus, decreased use of anti-inflammatory drugs, and shorter hospital stay with a lower complication rate, especially regarding the abdominal wall and blood loss. The robotic surgery was also incorporated into the surgical arsenal with results very similar to those of laparoscopy. Recently, several randomized controlled trials have demonstrated the efficacy, safety and equal oncologic results of laparoscopic distal gastrectomy in both early and advanced cancer. Methods: We reviewed the pivotal studies that promoted an advance in the distal laparoscopic gastrectomy since 1991. Conclusions: The good results obtained by subtotal gastrectomy studies, as well as in the robotic trials showed that the method can be incorporated in the arsenal of surgical techniques to treat distal gastric cancer. The only very difficult aspect to be solved is the cost, that seems insurmountable at the moment, especially for the robotic procedures, particularly in developing countries.