| Japanese Journal of Clinical Oncology | Pages |
References
Letters
Japanese Challenge to Gastric Cancer Surgeons: Add `Meticulous Accuracy' to Halsted's `Gentleness, Haemostasis and Minimal Trauma'
To the Editor:
I read with interest letters from British surgeons who have visited the gastric division of the National Cancer Center Hospital in Tokyo (1-3). While they give an accurate overview of the practice of gastric cancer surgery in a specialized unit they do not comment on the considerable difficulties that will have to be faced if radical gastrectomy Japanese-style is to be imported into routine British surgical practice.
I too had the opportunity to visit the NCCH and realize that the technical goals to which all surgeons should aspire, laid down as above by Halsted (4), have been redefined for radical gastrectomy by Japanese surgeons. It was very apparent to me during my stay at the NCCH that the surgeons I observed were master practitioners of their craft. The painstaking accuracy of bloodless dissection technique together with precise knowledge of anatomy was extremely impressive.
The single most important factor limiting the introduction into Britain of `routine' D2 gastrectomy is, I believe, that the `average' surgeon simply does not appreciate the level of meticulous accuracy of Japanese gastric cancer surgeons. Western surgeons are well aware that the typical patient in their practice is older and fatter and has much co-morbidity. This is customarily put forward as the reason why Western patients do badly compared to their younger and slimmer Japanese counterparts. Little emphasis is placed on the level of surgical ability that undoubtedly contributes to the low post-operative morbidity and mortality that distinguish Japanese results.
The attitude towards gastric cancer in the average British hospital, therefore, still tends to be that this is an untreatable disease with very poor survival. Several factors continue to promote this. Firstly, the disappointing initial results on operative mortality from the Dutch and MRC randomised controlled trials of D1 versus D2 gastrectomy have become fixed in the mind of many surgeons. Secondly, Japanese gastric cancer is still considered somehow `different' by many surgeons and the results not applicable to Western disease, despite evidence to the contrary. Further, the surgeon's attitude towards a diagnosis of gastric cancer is not helped by the majority of patients still presenting with advanced disease. Lastly, the declining number of patients in Britain has demoted gastric cancer away from being a priority in GI oncological surgery.
Altogether, these issues raise several questions regarding surgical training that are important but not easily answered.
Can D2 gastrectomy be performed to Japanese standards as a routine operation in non-specialized hospitals in Britain? To do so will require concerted effort to improve knowledge, operating skills and conditions, and may take a surgical generation. A change in attitude is needed, as highlighted by one consultant from the NCCH on a visit to Britain (5).
Halsted's criteria for operative skill as redefined by the Japanese now read `gentleness, haemostasis, minimal trauma and meticulous accuracy'. Unless it is to become an operation solely for specialists in referral centres, it is now up to British surgeons as a whole to make the most of their example and learn radical gastrectomy to the same standards as the Japanese.
C Richard B Welbourn
Senior Registrar
Department of Surgery
Frenchay Hospital
Bristol, United Kingdom
References
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