Abstract
Dear Editor
Having thoroughly reviewed your esteemed article titled “Laparoscopic vs. Open Gastrectomy for Locally Advanced Gastric Cancer: A Propensity Score-Matched Retrospective Case-Control Study” authored by Stefano Caruso et al. 1 I must express my profound appreciation for its comprehensiveness, inherent value, and worthiness. I wholeheartedly concur with your conclusion, asserting that laparoscopic gastrectomy, when coupled with D2 nodal dissection, exhibits a commendable level of safety and feasibility in terms of perioperative morbidity for patients afflicted with locally advanced gastric cancer. Moreover, your findings indicate that this minimally invasive approach showcases comparable oncological efficacy when juxtaposed with the more traditional open surgery. In an effort to further augment the robustness of your study and facilitate informed decision-making processes, I would like to proffer additional points of consideration.
This study suffers from a relatively diminutive sample size of 240 patients when compared to a retrospective cohort study encompassing 906 cases. The reduced sample size may compromise the statistical power and precision of the findings, thereby limiting their generalizability to a broader population. Furthermore, the study fails to elucidate the level of experience or expertise possessed by the surgeons involved in performing the surgical procedures. As surgeon skill and experience exert a substantial influence on surgical outcomes, the absence of information regarding the proficiency of surgeons in the specific technique being examined introduces a potential bias that could significantly impact the study’s results. 2 The study did not provide detailed information about the specific surgical procedure or technique employed. However, it hinted at the potential impact of innovative surgical techniques and advancements in surgical devices on enhancing the outcomes and efficiency of surgeries for early gastric cancer. Regarding the treatment of early gastric cancer, the study demonstrated the technical feasibility of laparoscopic-assisted total gastrectomy (LATG) utilizing the OrVil technique. This surgical approach involved adequate lymph node dissection, resulted in satisfactory early recovery, and yielded an acceptable morbidity rate. Nevertheless, further investigations with a larger cohort are required to substantiate the viability of this novel technique. 3 One notable limitation of the study is its limited evaluation of long-term outcomes. The focus of the study primarily revolves around short-term outcomes and technical feasibility, failing to address the effectiveness of neoadjuvant chemotherapy followed by gastrectomy in the long run. Long-term outcomes play a crucial role in providing valuable insights into the durability and sustainability of the treatment approach. They are essential for guiding clinical decision-making and patient management. Regarding the long-term outcomes analyzed in one particular study, the calculated 5-year disease-free survival rates were found to be 44.4% in the LG group and 53.2% in the OG group, with no significant difference observed between the two groups. The recurrence patterns were found to be similar between the LG and OG groups. Similarly, the calculated 5-year overall survival rates were reported as 46.9% in the LG group and 56.0% in the OG group, with no significant difference noted between the groups. Furthermore, it is worth mentioning that grade 3 or 4 toxic events occurred in 20% of patients in the LG group and 17% in the OG group, although the difference did not reach statistical significance. Among the observed adverse events, neutropenia was the most frequently reported, followed by leukopenia and anemia. Importantly, there were no reported cases of chemotherapy-related deaths. 4 This study refrains from conducting a direct comparative analysis of postoperative complications and their associated time requirements across diverse EJS techniques. However, it does acknowledge the existence of variations in outcomes and complications among the different methods. Notably, a distinct study demonstrates a significant correlation between circular methods and elevated incidences of both leakage and stenosis, as opposed to the utilization of the linear method. It is crucial to recognize that these factors hold potential implications for the overall outcome of the study. 5
In conclusion, the study by Caruso et al. contributes significantly to our understanding of laparoscopic gastrectomy for locally advanced gastric cancer. However, the aforementioned considerations, including sample size limitations, lack of surgeon expertise information, incomplete details on surgical techniques, and the need for long-term outcome evaluation and comparative analysis of EJS techniques, can further strengthen the study’s findings and facilitate informed decision-making processes.
