Is Laparoscopic/Robotic Total Gastrectomy a Reasonable and Adequate Treatment for Proximal Advanced Gastric Cancer?

Minimally invasive surgeries such as laparoscopic or robotic surgery for gastric cancer are becoming remarkably popular. Since the many robust pieces of evidence have been piled up, currently, the Japanese guidelines strongly recommend laparoscopic distal gastrectomy even for advanced cancer. However, regarding laparoscopic total gastrectomy (LTG) for advanced cancer, the technical difficulty is considerably higher because the tumor is likely to be large and is sometimes difficult to handle, and splenic hilar dissection is necessary in tumors that invade the greater curvature. So far, several studies have shown that the complication rate and survival outcomes are not inferior to those of open surgery, but the level of evidence is not high. In recent years, robotic surgery has become more penetrated in society. It is expected that especially in technically difficult procedures such as total gastrectomy, the advantages of robotic surgery could be exploited. In fact, several retrospective studies have suggested that robotic total gastrectomy reduces complications and increases the number of dissected lymph nodes compared to LTG. However, randomized trials are currently underway for these issues, and the results are awaited. In recent years, there has been a trend toward function-preserving surgery aimed at maintaining a patient's quality of life. Some retrospective studies suggested that total gastrectomy may not always be necessary, especially for proximal advanced gastric cancer with relatively small size and not high TN factor. All these points should be considered in the development of truly minimally invasive and curative procedures for patients.