According to the report, “Future Estimates of Cancer Incidence, Mortality, and Morbidity in Japan”, the incidence of gastric cancer will not change significantly, but the proportion of people aged 75 and older will increase significantly [3]. In these elderly patients, various comorbidities might be contraindications for radical surgery.
The radical gastrectomy for AGC results in reduced gastric volume and food intake, often leading to weight loss and decreased muscle mass. In addition, disorders, such as abdominal bloating, diarrhea, and dumping symptoms, may occur after gastrectomy, significantly reducing quality of life [4, 5]. Moreover, the postoperative complication rate appears to be high in elderly patients after gastrectomy [6, 7]. Thus, for elderly patients, it may be appropriate to reconsider their treatment strategy, with respect to the balance between quality of life and prognosis.
In the case of follow-up without curative surgery, such as best supportive care, it is often necessary to control the symptoms of AGC, such as bleeding and stenosis. For these cases, the gastro-jejunal bypass, radiation therapy and palliative gastrectomy without standard lymphadenectomy are often indicated. However, the risk of bleeding cannot be eliminated completely with gastro-jejunal bypass or palliative radiation therapy. Therefore, we consider LECS to be a good candidate for palliative treatment, as it is likely to suppress the symptoms of the gastric tumor with minimal invasiveness.
In 2014, LECS for submucosal tumors was covered by the Japanese National Health Insurance plan, and in 2020, gastric cancer was also covered. Classical LECS carries the risk of abdominal infection, scattering of tumor cells in the abdominal cavity, and dissemination of tumor cells in the peritoneum. However, the development of non-tumor-exposed LECS procedures, such as inverted-LECS, non-exposed endoscopic wall-inversion surgery (NEWS), and closed-LECS, has almost resolved these drawbacks [8]. Although, there are no reports of disseminated recurrence of gastric cancer after LECS, a careful selection of indications and careful post-operative follow-up should be demanded [9,10,11].
Here, we shed light on a new indication for LECS—"LECS as a palliative treatment of gastric cancer in the elderly". LECS as a palliative surgery was first reported by Takechi et al. in 2018 for a 68-year-old patient [12]; our patient was 89 years. Recently, Nunobe et al. used the National Gastric Cancer Registry to investigate the prognosis of 68,353 patients after Stage I gastric cancer resection, and found that deaths due to diseases other than gastric cancer were significantly increased in elderly people over 75 years who underwent conventional gastrectomy [13]. Furthermore, in this study, 2.6% of Stage I gastric cancer patients in this age group died due to a disease other than gastric cancer within 90 days after a radical gastrectomy [13]. These results show excessive surgical stress has a negative impact in terms of overall survival of patients who undergo radical gastrectomy for gastric cancer.
“LECS as a palliative treatment of gastric cancer in the elderly” has several issues that still need to be clarified. Based on our experience with LECS so far, we believe that there are a number of technical selection criteria necessary for the safe completion of LECS for gastric cancer. First, the size of the cancer should be 5 cm or less, because if the defect in the stomach wall after tumor resection is too large, there may be a high degree of deformation after reconstruction resulting in a delay in gastric emptying. Second, AGC, such as types 3 and 4, might not be indicated for LECS procedures, because the tumor margins are usually difficult to recognize. Third, the location of the tumor is important, as tumors located near the esophagogastric junction or pyloric ring are technically demanding and should not be treated with LECS. In addition, a wide disconnection of the nerve of Latarjet interferes with gastric peristalsis, so LECS should not be planned if the tumor extends widely to both the anterior and posterior walls of the stomach.
However, most importantly, the patient should not be offered palliative LECS in the first instance. Currently, LECS is an option that should only be offered after the patient has refused standard curative treatment. In this current case, our patient totally refused radical gastrectomy for gastric cancer. Other than best supportive care, the only treatment she agreed to was LECS. As a result of the LECS, she has been able to live her desired life at home for 2 years.
Another technique used in LECS is also important for producing a cancer-negative dissection margin. We perform a full-circumferential negative biopsy before the surgery to determine the minimum required dissection line. Furthermore, the preoperative intra-luminal endoscopic mucosal ablation marked by electrocautery makes the dissecting line more accurate. In contrast, a simple wedge resection which is the most popular procedure for gastric local resection might result in cancer-positive margins because of the difficulty in determining the extent of the lesion from the outside of the stomach wall [14].
Furthermore, there are several modified LECS procedures which do not expose the tumor to the abdominal cavity, such as NEWS, closed-LECS, and CLEAN-NET (combination of laparoscopic and endoscopic approaches to neoplasia with a non-exposure technique). Despite the excellent performance of these procedures, they are not easy to perform for every tumor location and size. That is why we used the gastric content-scatterless procedure named “inverted-LECS” in this case, which sufficiently prevents intraoperative cancer cell seeding. Inverted-LECS is technically easy, and it can be performed regardless of tumor location or size.
Local control of AGC with LECS, in terms of preventing tumor bleeding or stenosis, might be an option for palliative treatment of patients with gastric cancer in the future. To prove the safety and efficacy of palliative LECS for gastric cancer as a less invasive surgery, further large-scale studies are warranted.
