Japanese Journal of Clinical Oncology Advance Access originally published online on December 16, 2005
Japanese Journal of Clinical Oncology 2006 36(1):64; doi:10.1093/jjco/hyi209
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© 2005 Foundation for Promotion of Cancer Research
Letter |
The Myth of Thin Patients as Explanation for the Excellent Results of the Japanese Technique in the Surgical Treatment of Gastric Cancer
Surgery Department, Rebagliati National Hospital Lima, Peru E-mail: michelportanova{at}yahoo.com
To the Editor:
Surgery remains the only treatment for cure of gastric cancer, and excellent results (operative morbidity/mortality, long-term survival) of Japan have always been referred to by worldwide gastric surgeons. One of the possible explanations of the good results is their extended D2 lymphadenectomy. However, these could not be reproduced in the Western prospective studies (1,2), where D2 was associated with significantly higher mortality but not with survival benefit as compared to D1. There were several problems in these trials, e.g. most of the participating surgeons were not familiar with D2 procedure and post-operative management, and pancreaticosplenectomy was too frequently employed.
I am afraid surgeons who have never performed D2 could not perform proper D2. I have personally found that some Western surgeons are reluctant to accept the superiority of the Japanese technique simply because they have never been trained for this procedure. They seem to be ignorant that D2 is technically not difficult, though it requires some training period and a learning curve.
Some Western surgeons try to explain the excellent Japanese results by the fact that Japanese patients are very thin and thus suitable for meticulous lymphadenectomy. However, during my last visit to the National Cancer Center Hospital, Tokyo, I found this was not necessarily the case. I visited the Gastric Surgery Division for 3 months as part of the training program sponsored by the Japan International Cooperation Agency. During this period I certainly saw many thin patients undergoing ‘bloodless’ surgery, but to my surprise, many ‘Western type’ patients as well were being treated by the same technique. Of course it was not as easy as in thin patients, but I was convinced that extended lymphadenectomy even larger than D2 could be safely performed in obese patients using the same meticulous technique and minimal trauma as in classical Japanese patients.
I believe that the excellent results of the Japanese technique must also be analysed under the light of subspecialization. For example, the National Cancer Center Hospital is itself a specialized institution for cancer care, and moreover, it has an exclusive division for gastric cancer with five staff surgeons who perform more than 500 gastrectomies in total every year. This subspecialization has given the surgeons deep knowledge of surgical anatomy that can only be reached by making the same type of surgery in a constant and reiterated way. I am sure that this provides the best surgical performance for the patients.
In conclusion, I am convinced that there are at least three reasons to explain the good result of Japanese surgery for gastric cancer: (a) the safe, meticulous D2 lymphadenectomy to eradicate local disease, (b) the centralization of disease care to referral hospitals, (c) the implementation of subspecialized surgical teams. Under such circumstances as (b) and (c), even ‘Western type’ patients could undergo Japanese style gastrectomy. It seems unjust and stingy to me to insist that the patients' thinness is the main reason for the excellent surgical achievements of Japanese surgeons.
References
1 Japanese Research Society for Gastric Cancer. Treatment Results of Gastric Carcinoma in Japan: 39th Report of Nation Wide Registry in 1979–82. Tokyo: National Cancer Center press 1995.
2 Maruyama K, Okabayashi K, Kinoshita T. Progress in Gastric Cancer surgery in Japan and its limits for radicality. World J Surg 1987;11:418–26.[CrossRef][ISI][Medline]
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