Is Laparoscopic/Robotic Total Gastrectomy a Reasonable and Adequate Treatment for Proximal Advanced Gastric Cancer - Annals of Gastroenterological Surgery

Sep 28, 2026

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Minimally invasive surgery for gastric cancer is increasingly common, and Japanese guidelines strongly recommend laparoscopic distal gastrectomy even for advanced disease. For laparoscopic total gastrectomy (LTG) in advanced cancer, technical difficulty is higher due to large tumors, handling challenges, and the need for splenichilar dissection when the greater curvature is invaded. Existing studies suggest comparable complication and survival outcomes versus open surgery, though evidence remains limited. Robotic total gastrectomy may reduce complications and increase retrieved lymph nodes based on retrospective data, while randomized trials are ongoing. For proximal advanced gastric cancer, function-preserving strategies may make total gastrectomy unnecessary in selected cases, including relatively small tumors with limited TN factors, requiring careful consideration when designing curative minimally invasive approaches.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages12

Reading Time30 min

AccessFree to download

Introduction

Standard treatment and chemotherapy context

Minimally invasive approaches and evidence gaps

Challenges of advanced proximal disease

Role and limitations of robotic surgery

Additional considerations

Function-preserving trends in proximal advanced cases

Annals of Gastroenterological Surgery Is Laparoscopic/Robotic Total Gastrectomy a Reasonable and Adequate Treatment for Proximal Advanced Gastric Cancer? Takahiro Kinoshita | Masahiro Yura | Mitsumasa Yoshida | Daiki Terajima Gastric Surgery Division, National Cancer Center Hospital East, Kashiwa, Japan Correspondence: Takahiro Kinoshita ([takkinos@east.ncc.go.jp](takkinos@east.ncc.go.jp)) Received: 30 June 2025 | Revised: 3 August 2025 | Accepted: 12 August 2025 Funding: The authors received no specific funding for this work. Keywords: gastric cancer | laparoscopic total gastrectomy | lymph node dissection | proximal gastric cancer | robotic total gastrectomy ABSTRACT Minimally invasive surgeries such as laparoscopic or robotic surgery for gastric cancer are becoming remarkably popular. Since the many robust pieces of evidence have been piled up, currently, the Japanese guidelines strongly recommend laparoscopic distal gastrectomy even for advanced cancer. However, regarding laparoscopic total gastrectomy (LTG) for advanced cancer, the technical difficulty is considerably higher because the tumor is likely to be large and is sometimes difficult to handle, and splenichilar dissection is necessary in tumors that invade the greater curvature. So far, several studies have shown that the complication rate and survival outcomes are not inferior to those of open surgery, but the level of evidence is not high. In recent years, robotic surgery has become more penetrated in society. It is expected that especially in technically difficult procedures such as total gastrectomy, the advantages of robotic surgery could be exploited. In fact, several retrospective studies have suggested that robotic total gastrectomy reduces complications and increases the number of dissected lymph nodes compared to LTG. However, randomized trials are currently underway for these issues, and the results are awaited. In recent years, there has been a trend toward function-preserving surgery aimed at maintaining a patient's quality of life. Some retrospective studies suggested that total gastrectomy may not always be necessary, especially for proximal advanced gastric cancer with relatively small size and not high TN factor. All these points should be considered in the development of truly minimally invasive and curative procedures for patients. 1 | Introduction A standard surgical treatment for locally advanced gastric cancer is radical gastrectomy with an adequate range of lymph node (LN) dissection with the intention of local disease control [1] . In recent years, perioperative chemotherapy has been combined as needed to enhance treatment efficacy. Perioperative FLOT has been the standard treatment in the West [2], but lately, the Matterhorn trial [3], a phase III trial, proved the superiority of FLOT plus Durvalumab, an anti-PD-L1 antibody, and the standard treatment is expected to change. In the East, including Japan, postoperative adjuvant therapy has been the standard, but with the results of the PRODIGY [4] and RESOLVE [5] trials, an increasing number of centers are now offering perioperative chemotherapy [6] . Current Japanese guidelines do not provide clear recommendations for perioperative chemotherapy since the results of the phase III study in the Japanese population only are not available [1] . Minimally invasive surgeries such as laparoscopic gastrectomy (LG) and robotic gastrectomy (RG) for gastric cancer are becoming remarkably popular. Since the many robust evidence has been piled up, currently, Japanese guidelines strongly recommend laparoscopic distal gastrectomy (LDG) even for advanced This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. © 2025 The Author(s). Annals of Gastroenterological Surgery published by

FAQs

Why is laparoscopic total gastrectomy (LTG) considered technically more difficult for advanced proximal disease?

Advanced tumors are often large and harder to handle, and splenichilar dissection is required when the greater curvature is invaded.

What evidence suggests robotic total gastrectomy could improve outcomes compared with LTG?

Retrospective studies indicate robotic total gastrectomy may reduce complications and increase the number of dissected lymph nodes versus LTG.

What ongoing research is mentioned regarding LTG versus open surgery and robotic approaches?

Randomized trials are underway for key comparisons, and results are awaited, including trials addressing LTG versus open total gastrectomy and robotic benefits.

Sep 28, 2026

Uploaded by dawugda