© 2004 Foundation for Promotion of Cancer Research
Letter |
‘Those who can do; those who can teach’ Management of Gastric Cancer in Japan
Department of Surgery, Worthing and Southlands Hospitals, West Sussex, UK E-mail: mazin.sayegh{at}wash.nhs.uk
To the Editor:
Japanese surgeons have long been ahead of the rest of the world in the management of gastric cancer. Their success in achieving a high curative rate was always debated and even doubted by the West, until Western doctors started visiting the National Cancer Centre Hospital in Tokyo (NCCH) and witnessed for themselves the success of Japanese doctors. I did not go to the NCCH to allay my doubts. I had been converted already, thanks to Mr Andy Wyman at the Northern General Hospital, Sheffield, UK, who had taught me the Japanese D2 gastrectomy and encouraged me to visit the NCCH.
It was B.G.A. Moynihan who said ‘Surgery of malignant disease is not the surgery of organs; it is the anatomy of the lymphatic system’ (1). This is without doubt a basic principle of the Japanese surgical practice. I, like the rest of my predecessors (2–4) who have visited the NCCH, share the same views with regard to the practice of gastric cancer surgery and management of patients in a specialised unit. However, I would like to reflect on several points.
I was impressed by the accurate documentation of the endoscopic, surgical and pathological findings. An informative drawing of the surgical procedure is always included in the notes, in addition to the resected surgical specimen and endoscopic photographs.
The operative procedures themselves are inspiring to watch, with competent and meticulous dissection of the relevant lymph nodes. Anatomical structures are clearly presented, with full awareness of the various anomalies. I witnessed the delicate procedure of pancreas preserving total gastrectomy, in addition to proximal gastrectomy with jejunal interposition and pylorus-preserving gastrectomy for early gastric cancer, which were all quite new to me. There was great emphasis on drainage tubes, the colour and volume of the discharge, and the option of changing the position of these tubes under X-ray control to ensure adequate and effective drainage.
I was surprised to learn that the Japanese doctors are shifting their practice from extensive radical surgery with organ exenteration for advanced gastric cancer to tailored operations for each individual patient depending on the type and location of the lesion. They are also keen to randomise patients into various trials of adjuvant and neo-adjuvant chemotherapy, with the patient's consent after appropriate counselling and explanation.
Thoughts & reflections
Are we missing early gastric cancer cases in the UK? If so, is it because we have no proper screening programme? Or is it because of our endoscopic deficiency in diagnosing early gastric cancer? It is not cost effective and worthwhile to screen in the UK, since the incidence is not as high as in Japan. Needless to say we should learn more from the Japanese if we are not to miss the few cases of early gastric cancer we see. The problem of restricted and overcrowded endoscopy sessions and lack of staff is a major concern and has been continuously addressed.
Why do we have more complications with our D2 gastrectomy? Is it our surgical technique or patient selection? There is no doubt that our patients are fatter and less fit, with deep abdominal cavity and higher pre-morbid factors such as atherosclerosis and postoperative deep venous thrombosis, which are uncommon in Japanese patients.
CONCLUSION
It was George Bernard Shaw who said ‘those who can do; those who can not teach’. I beg to differ on this, especially after visiting the NCCH and seeing the surgeons who are not only good doers but also excellent teachers. As much as I am impressed and excited with Japanese methods of management of gastric cancer, I am also disheartened by the fact that I might not be able to implement such practice in the UK as a result of the following: (i) The considerable difficulties faced especially with limits imposed on operation time in an era of long patient waiting lists and frequent cancellations. Adding to this uphill struggle is the daunting discontent and grumble of theatre staff one has to face during lengthy procedures. (ii) The opposition by those surgeons who believe that gastric cancer is an incurable disease with poor prognosis, regardless of the method of treatment and the type of surgery implemented. Unfortunately, this belief has been erroneously deepened after the misinterpretation of the published Dutch and British trials of D1 versus D2 gastrectomy.
The impressive results of the NCCH in treating gastric cancer reinstate the benefits of concentrating surgery in specialised units whereby a team of experienced surgeons can perform a procedure with minimum risk to the patient and maximum treatment efficiency. This is the basic inspiration behind ‘The Clinical Outcome Guidance document for the management of cancer in England and Wales’ (5), and as reported by McArdle and Hole (6), if the average surgical standard could be raised to the level achieved by the best surgeons, the improvement in patients' outcome might equal or surpass anything currently achieved by means of adjuvant therapy.
Acknowledgments
I am very grateful for the generous financial support of the Japanese Foundation for Promotion of Cancer Research and the British Council.
References
1 Moynihan BGA. The surgical treatment of cancer of the sigmoid flexure and rectum. Surg Gynecol Obstet 1908;6:463–6.[Web of Science]
2 Martin IG. An Englishman abroad—thoughts on the Japanese management of gastric cancer. Jpn J Clin Oncol 1996;26:283–4.
3 Preston SR. East is east and west was west: closing the gap in the delivery of gastric cancer surgery. Jpn J Clin Oncol 2001;31:469–70.
4 Reid I. Management of early gastric cancer in Japan. Jpn J Clin Oncol 1997;27:119.
5 Guidance on the commissioning of cancer services. Improving outcomes in upper gastro-intestinal cancer. www.doh.gov.uk/cancer/pdfs/intestinalmain.pdf. 2001.
6 McArdle CS, Hole D. Impact of variability among surgeons on post-operative morbidity and mortality and ultimate survival. BMJ 1991;302:1501–5.
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