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Japanese Journal of Clinical Oncology 30:369-370 (2000)
© 2000 Foundation for Promotion of Cancer Research
Letters to the Editor |
Lessons in Treatment of Gastric Cancer: Viewpoint of a UK Surgeon
To the Editor:
I think it was a Frenchman who said that good teachers did not satisfy your thirst for knowledge—they made you more thirsty. For this reason, I had mixed emotions when my boss asked me if I wanted to go to The National Cancer Center Hospital in Tokyo to see how gastric operations really should be done. My immediate response was to grab the opportunity of visiting a centre where the reputation for gastric operating was second to none. My second response was concern about how I, a strict teetotal vegetarian, would survive in a country whose culinary habits revolved around fish and meat. One downward glance at my ample abdominal girth (which had been slowly but surely increasing over the years) convinced me that as far as body fat was concerned I had more than enough to keep me going.
So off I went. I arrived a little jetlagged but nevertheless very excited about the prospect of meeting some of the world’s greatest gastric surgeons. My next 2 weeks were to be not only very informative but also highly enjoyable.
The Gastric Division of the National Cancer Centre Hospital in Tokyo has four staff surgeons. Collectively they perform about nine gastrectomies each week. They pay great attention to all aspects of the patients under their care and work together as a team. I was to find that they were typical of the Japanese in that they did what they did well and what they didn’t do well they didn’t do at all. Hence the Gastric Division dealt purely with gastric cancer. Oesphageal cancer was dealt with by the Thoracic Oesophageal Surgeons.
Preoperative Assessment
This was very thorough. Each patient was assessed by a consultant member of the team in the preoperative clinic and a management plan established. The work-up of any patient with suspected gastric cancer includes a double contrast barium meal, an endoscopy (with indigo carmine spray, endoscopic ultrasonography and biopsy) and CT scanning. Endoscopy is undertaken by skilled endoscopists who are typical of Japanese surgeons and Japanese tourists—they photograph just about anything which is photographable! A typical upper endoscopy includes an average of 40 photographs! Every Friday afternoon, all investigations were available for discussion by the consultant surgeons and junior staff as well as radiologists and endoscopists. In this way an exact preoperative diagnosis was made and an appropriate operation planned. Laparoscopy was rarely used as a diagnostic technique and was used mainly to detect peritoneal seeding where this was not apparent preoperatively.
Operative Technique
Some of the finest operating I have yet seen was in the National Cancer Center Hospital. Peritoneal cytology is performed routinely for all advanced gastric cancers. I saw a number of D2 and D3 gastrectomies. Blood loss, even in the larger ‘Westernised’ patients, was rarely more than double figures. The quality of lymphatic dissection and clearance was beyond compare. I realised that it was important to have good access to the peritoneal cavity (the incisions even in the thin patients extended well below the umbilicus) and to have good-quality assistants and scrub nurses. Equally important was the ability to be patient. Lymphatic clearance takes time. The excised specimen is opened and carefully examined in theatre by the operating consultant. Photographs are taken. It is then transported to the pathology department where two of the junior surgical staff meticulously dissect the different lymph node groups (which have not been removed at the time of operation) and place them in separate containers for histological examination. The pathologists then take even more photographs for themselves.
Postoperative Care
Postoperative ward rounds took place every morning and started at 07.45 h exactly in the Hyperdependancy Unit. All the consultant surgeons and junior staff were present. Only patients with drains in situ were regularly seen by the consultant staff. Japanese patients stay in hospital for some time after their operation. They find it reassuring that in the convalescent phase of their recovery they will be close to the staff who know them and their operation well. In this respect Japanese patients remain in hospital for some weeks. This is in stark contrast to Britain where patients often wish to return home as soon as it is safe to do so (and even before, sometimes!).
What did I learn?
I learned a great deal even in the short time that I was there. Mostly I learned that a lot of what I already knew was true. Gastric cancer is a curable disease. It can be diagnosed early and can even be resected endoscopically in some cases. Even where a conventional operation is necessary the chances of cure are high if the correct operation is performed. Morbidity and mortality are low. I realised that lymph nodes and lymphatic channels do act as filters to slow and trap the migration of neoplastic cells from the stomach to the systemic circulation and that their removal does protect from recurrence. This too was in contrast to what I had been taught at medical school—that removal of lymph nodes did not confer any survival advantage but was performed to allow staging of the neoplasm. I learned that blood transfusion should rarely if ever be necessary for an elective operation.
What is different?
Much of the Japanese system is similar to that in the UK. There is a real commitment to managing gastric carcinoma by the best possible means. To this end the unit has resources which allow it to meet this dedication. There is a plethora of computing facilities in the wards as well as in each operating theatre. Investigations are immediately available as are the results (usually on computer—including radiological tests). Attention to detail is seen everywhere—a philosophy very much close to the heart of the Japanese.
The overriding message which I received from my visit to this unit was one of attention to detail, dedication to the detection and treatment of gastric cancer and teaching the craft to junior staff. The only aspect of patient care which was lacking was research. The Japanese are avid collectors of data and as clinicians they are great auditors. They have a wealth of data and a very efficient means of collecting it. This could be put to very good use. Although some studies (such an evaluation of different types of gastrectomy for advanced gastric cancer and an evaluation of transhiatal and Ivor Lewis oesophagectomy for cancer of the cardia) are in progress, the throughput of patients combined with the low morbidity and mortality (and hence high survival) makes this unit ideal for a number of clinical and science-based research programmes. Perhaps the West and the East can combine resources to address the issue of research. I hope so.
Now where’s that glass of water? I have a thirst like you don’t want to know. . . .
Ramesh Gupta
Senior Registrar in Surgery, Southampton General Hospital,
Southampton, UK
.
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