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van den Berg et al. Mini-invasive Surg 2019;3:23 I http://dx.doi.org/10.20517/2574-1225.2019.07 Page 5 of 9

and laparoscopic techniques in the specialty of Gastro-Oesophageal surgery [26,27] . A recent meta-analysis
[28]
described the results of ERAS in LG patients . In this analysis of six studies, with predominantly patients
who underwent a LDG, ERAS resulted in shorter LOS (WMD - 2.65; P < 0.01) and less hospitalisation
expenditure (WMD - 523.43; P < 0.01). However, no significant difference was found regarding complication
rate. This meta-analysis shows that ERAS can be applied to laparoscopic gastric surgery. However, large
sample RCT’s should be conducted to fully show the effect of an ERAS program in LG patients.

LEARNING CURVE
A LTG remains a challenging surgical procedure with substantial technical difficulties, such as the
extended lymph node dissection and the anastomoses of the oesophagus to the jejunum. Limited studies
have addressed the learning curve for LTG. A Korean study described that the learning curve for LTG is
[29]
approximately 100 cases . Earlier, another Korean study described using the cumulative sum technique
[30]
showed that postoperative morbidity reached a plateau after around 45 cases . In addition, for LDG a
[31]
learning curve of 20 to 40 cases has been reported . Overall, these studies show that a lengthy learning
curve will be required to achieve acceptable morbidity. In addition, the learning curve for LTG in the
Western countries may differ as in general this includes patients with more advanced gastric cancer as well
as higher BMI.

CENTRALISATION
Worldwide centralisation for the care for gastric cancer patients is increasing. In the Netherlands it has
been imposed since 2012. A recent analysis on the outcomes from this process has shown an increase in
[32]
the utilisation of laparoscopic surgery for gastric cancer from 6% to 40% (P < 0.01) . Whilst the volume
of laparoscopic surgery has increased, adequate lymphadenectomy has improved from 21% to 93% (P <
0.01). Other benefits included decreased median LOS (8 days vs. 10 days; P < 0.01), and greater utilisation
of perioperative chemotherapy (25% vs. 42%; P < 0.01). They reported no significant change in 30-day
mortality (4.2% vs. 1.9%; P = 0.17), 1 year overall (78% vs. 80%; P = 0.17) and disease-free survival (73%
vs. 74%; P = 0.66). This demonstrates that in western countries, centralisation of gastric cancer results in
better rates of laparoscopic resection, improved short term outcomes without impacting on postoperative
mortality and intermediate-term survival.

TECHNICAL ASPECTS OF LG
Anastomoses technique
LTG is technically difficult. The main concerns are the anastomoses technique and oncological safety.
Currently there is no standardised method for the esophago-jejunostomy, and many different techniques
have been described. A retrospective study in 687 patients who underwent a LTG compared oesophago-
jejunostomy using a linear stapler with a circular stapler . Complication rates were similar between
[33]
the two groups, however the linear stapler resulted in a shorter operation time (149 min vs. 170 min, P <
0.001) as well as shorter length of hospital stay. Therefore, concluded was that a linear stapler technique
for an oesophago-jejunostomy is a feasible procedure. A retrospective study compared a circular stapler
TM
[34]
(OrVil ) esophago-jejunostomy with an overlap esophago-jejunostomy using a linear stapler . The rate
TM
of anastomotic anastomotic leakage was lower in the linear stapler group compared with the OrVil
group (0.7% vs. 4.1%) although this was not significant. In addition, the rate of anastomotic stenosis was
TM
significantly lower in the linear stapler group compared with the OrVil group (0.0% vs. 4.1%, P = 0.017).
However, there are no RCT’s comparing the optimal anastomoses technique in patients undergoing LTG.
Extent of lymph node dissection
Numerous studies have reported the impact of lymph node dissection on survival in gastric cancer surgery.
Fifteen year follow up of a Dutch trial comparing a limited lymph node dissection (D1) with an extended