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  Table of Contents  
REVIEW ARTICLE
Year : 2015  |  Volume : 52  |  Issue : 1  |  Page : 36-38
 

Bursectomy for gastric cancer: What does the evidence indicate?


Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, Haryana, India

Date of Web Publication3-Feb-2016

Correspondence Address:
A Chaudhary
Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.175564

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 » Abstract 

Radical resection of the bursa omentalis (radical bursectomy) as part of a curative resection for gastric cancer has been advised for close to a century. However, the postulated associated morbidity and lack of a clear benefit in terms of survival preclude its routine use. To objectively review the available evidence on the role of bursectomy as part of a curative resection for gastric cancer. A systematic search of the scientific literature was carried out using Embase, PubMed, MedLine and the Cochrane central register of controlled trials for the years 1965-2013 to obtain access to all publications, especially randomized controlled trials (RCTs), systematic reviews and meta-analyses involving bursectomy in gastric cancer with the appropriate specific search terms, namely, “bursectomy,” “stomach cancer,” “gastric cancer,” “survival,” “morbidity,” “outcomes” and “RCTs”. Using the above search strategy, a total of 29 publications was retrieved of which five publications were identified describing bursectomy and its outcomes in gastric cancer. These included three retrospective cohort studies and two publications from a single RCT. Bursectomy do not appear to add the morbidity or mortality of the overall surgery. However, it did not appear to significantly improve overall survival neither in the retrospective cohort studies nor in the only RCT. The evidence to date is insufficient to suggest any additional benefit of routine bursectomy to a radical gastrectomy with D2 lymphadenectomy for gastric cancer. Results of an on-going RCT are awaited to determine if bursectomy may further improve overall survival in patients with advanced T-stage of disease.


Keywords: D2 lymphadenectomy, morbidity, mortality, radical


How to cite this article:
Barreto S G, Perwaiz A, Singh A, Singh T, Chaudhary A. Bursectomy for gastric cancer: What does the evidence indicate?. Indian J Cancer 2015;52:36-8

How to cite this URL:
Barreto S G, Perwaiz A, Singh A, Singh T, Chaudhary A. Bursectomy for gastric cancer: What does the evidence indicate?. Indian J Cancer [serial online] 2015 [cited 2019 Aug 25];52:36-8. Available from: http://www.indianjcancer.com/text.asp?2015/52/1/36/175564



 » Introduction Top


Locoregional recurrences in gastric cancer have been reported to be as high as 72%.[1],[2] Radical resection of the bursa omentalis (radical bursectomy) as part of a curative resection for gastric cancer has been advised for close to a century [3],[4],[5] as one of strategies to reduce locoregional recurrence. Bursectomy involves the dissection of the peritoneal lining of the lesser sac (the lining over the anterior transverse mesocolon and pancreas) along with omentectomy [4],[6] and forms part of the recommendations in the Japanese Gastric Cancer Treatment Guidelines on surgery for gastric cancer.[5] The rationale for this procedure is that it aids removal of micrometastases disseminated into the bursa omentalis especially in gastric cancers located in the posterior wall where it may constitute the only site of disease dissemination [7] as well to facilitate a more thorough clearance of the infrapyloric and celiac nodes.[8]

Although theoretically, radical bursectomy should be part of a curative resection for gastric cancer, factors precluding its widespread practice include the associated morbidity and lack of a clear benefit in terms of survival. The aim of the current study was to objectively review the available evidence on the role of bursectomy as part of a curative resection for gastric cancer.


 » Materials and Methods Top


A systematic search of the scientific literature was carried out using Embase, PubMed, MedLine and the Cochrane central register of controlled trials for the years 1965-2013 to obtain access to all publications, especially randomized controlled trials (RCTs), systematic reviews and meta-analyses involving bursectomy in gastric cancer. The search strategy was that described by Dickerson et al.[9] with the appropriate specific search terms, namely, “bursectomy,” “stomach cancer,” “gastric cancer,” “survival,” “morbidity,” “outcomes” and “RCTs.” All available publications from the past 50 years were considered.

Inclusion criteria

Studies specifically addressing the role of bursectomy in gastric cancer specifically:

  • Perioperative morbidity and mortality
  • Overall survival.


Exclusion criteria

Studies including lymphadenectomy, anastomotic techniques and extent of resection in which no reference to the outcomes related to bursectomy were reported.


 » Results Top


Using the above search strategy, a total of 29 publications was retrieved of which five publications [Figure 1] were identified describing bursectomy and its outcomes in gastric cancer. These included three retrospective cohort studies and two publications reporting the perioperative outcomes and survival from a single RCT.
Figure 1: Quorum chart

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[Table 1] provides a detailed overview of the publications analysed.[10],[11],[12],[13],[14]
Table 1: Comprehensive overview of the studies included in the review along with the pertinent details

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 » Discussion Top


The review of literature indicates that bursectomy does not appear to add to morbidity [10],[11],[13] or mortality [10],[13] of the overall surgery. However, it did not appear to significantly improve overall survival neither in the retrospective cohort studies [11],[12] nor in the only RCT.[10],[13] The trial by Fujita et al.[13] did indicate a lower incidence of peritoneal recurrences in those patients undergoing a bursectomy (8.7% vs. 13.2%) as well as a difference in 3-years overall survival for patients with T3/T4 serosa-positive disease (69.8% vs. 50.2%; P = 0.791). However, the study was designed as a non-inferiority trial. On balance, it needs to be pointed out that the series reporting on morbidity and mortality were both from Japan and included surgeons well experienced with radical gastric surgery.[10],[11],[13] The only study from outside of Japan was a retrospective cohort study recently published by Blouhos et al.[14] These authors from Greece, however, did not include a comparative group in their analysis, which precludes the derivation of valuable conclusions on whether the additional performance of bursectomy resulted in an increased morbidity or mortality. Thus, the existence of a “learning curve,” if any was not assessed in any of these studies.

Strategies to reduce the probability of locoregional recurrence following curative resection for gastric cancer include clear resection margins, extensive lymphadenectomy and radical resection of the bursa omentalis. Accumulating evidence has clearly indicated the benefit of clear resection margins on overall survival.[15] In terms of the extent of lymphadenectomy, the existing evidence has firmly indicated the lack of benefit of extended lymphadenectomy to include paraaortic lymph nodes [16] resulting in gastrectomy with D2 lymphadenectomy (that encompasses the second echelon of draining lymph nodes [N2]) as standard of care for resectable gastric cancer.[17]

As noted earlier, bursectomy is intended to serve two main purposes – facilitating clearance of micrometastatic disease from the bursa omentalis as well as improve the radicality of celiac and infrapyloric nodal dissection. Work by Yamamura et al.[18] suggested that cancer cells shed from the primary tumor and disseminated into the bursa omentalis are either eliminated or migrate swiftly into the free abdominal cavity and are thus unlikely to be optimal targets for surgical removal. On the other hand, adding a bursectomy does not appear to alter the lymph node yield as per the RCT by Imamura et al.[10] (median lymph nodes 38 vs. 37, p-NS).

The important question remains – do we even need to explore the role of bursectomy in gastric cancer any further. Recurrent disease in the gastric bed following a curative resection accounts for up to 20% of locoregional recurrences.[1],[19] These recurrences are notorious for being unresectable.[20] Thus, it is appears essential to determine if adding a bursectomy to D2 gastrectomy at least for disease >T3 to determine if it leads to a reduction in local tumor bed recurrences and affects overall survival. The JCOG1001, Bursectomy Phase III trial (Clinical Trials no: UMIN000003688) is currently underway in Japan to determine the benefit of adding a bursectomy to D2 lymphadenectomy in patients with cT3/T4 disease followed by adjuvant chemotherapy. The primary outcome of this measure in this trial is the overall survival with progression free survival along with perioperative markers as a secondary outcome measures. This trial will hopefully provide a more clear direction for research on the role of bursectomy in gastric cancer.


 » Conclusions Top


The evidence to date is insufficient to suggest any additional benefit of routine bursectomy to a radical gastrectomy with D2 lymphadenectomy for gastric cancer. Results of an ongoing RCT are awaited to determine if bursectomy may further improve overall survival in patients with advanced T-stage of disease.

 
 » References Top

1.
D'Angelica M, Gonen M, Brennan MF, Turnbull AD, Bains M, Karpeh MS. Patterns of initial recurrence in completely resected gastric adenocarcinoma. Ann Surg 2004;240:808-16.  Back to cited text no. 1
    
2.
Macdonald JS, Smalley SR, Benedetti J, Hundahl SA, Estes NC, Stemmermann GN, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 2001;345:725-30.  Back to cited text no. 2
    
3.
Jinnai D. Theory and practice of the extended radical operation for gastric cancer. Rinsho Geka 1967;22:19-24.  Back to cited text no. 3
    
4.
Groves EW. On the radical operation for cancer of the pylorus: With especial reference to the advantages of the two-stage operation and to the question of the removal of the associated lymphatics. Br Med J 1910;1:366-70.  Back to cited text no. 4
    
5.
Hagiwara A, Sawai K, Sakakura C, Shirasu M, Ohgaki M, Yamasaki J, et al. Complete omentectomy and extensive lymphadenectomy with gastrectomy improves the survival of gastric cancer patients with metastases in the adjacent peritoneum. Hepatogastroenterology 1998;45:1922-9.  Back to cited text no. 5
    
6.
Oglivie W. Cancer of the stomach. Surg Gynecol Obstet 1939;68:295-305.  Back to cited text no. 6
    
7.
Japanese Gastric Cancer Association. Gastric cancer treatment guidelines. Tokyo: Kanehara; 2004.  Back to cited text no. 7
    
8.
Hundahl SA. The potential value of bursectomy in operations for trans-serosal gastric adenocarcinoma. Gastric Cancer 2012;15:3-4.  Back to cited text no. 8
    
9.
Dickersin K, Scherer R, Lefebvre C. Identifying relevant studies for systematic reviews. BMJ 1994;309:1286-91.  Back to cited text no. 9
    
10.
Imamura H, Kurokawa Y, Kawada J, Tsujinaka T, Takiguchi S, Fujiwara Y, et al. Influence of bursectomy on operative morbidity and mortality after radical gastrectomy for gastric cancer: Results of a randomized controlled trial. World J Surg 2011;35:625-30.  Back to cited text no. 10
    
11.
Kochi M, Fujii M, Kanamori N, Kaiga T, Mihara Y, Funada T, et al. D2 Gastrectomy with versus without bursectomy for gastric Cancer. Am J Clin Oncol 2012;[Epub ahead of print].  Back to cited text no. 11
    
12.
Yoshikawa T, Tsuburaya A, Kobayashi O, Sairenji M, Motohashi H, Hasegawa S, et al. Is bursectomy necessary for patients with gastric cancer invading the serosa? Hepatogastroenterology 2004;51:1524-6.  Back to cited text no. 12
    
13.
Fujita J, Kurokawa Y, Sugimoto T, Miyashiro I, Iijima S, Kimura Y, et al. Survival benefit of bursectomy in patients with resectable gastric cancer: Interim analysis results of a randomized controlled trial. Gastric Cancer 2012;15:42-8.  Back to cited text no. 13
    
14.
Blouhos K, Boulas KA, Hatzigeorgiadis A. Bursectomy in gastric cancer surgery: Surgical technique and operative safety. Updates Surg 2013;65:95-101.  Back to cited text no. 14
    
15.
Resection line disease in stomach cancer. British stomach cancer group. Br Med J (Clin Res Ed) 1984;289:601-3.  Back to cited text no. 15
    
16.
Sasako M, Sano T, Yamamoto S, Kurokawa Y, Nashimoto A, Kurita A, et al. D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer. N Engl J Med 2008;359:453-62.  Back to cited text no. 16
    
17.
Ott K, Lordick F, Blank S, Büchler M. Gastric cancer: Surgery in 2011. Langenbecks Arch Surg 2011;396:743-58.  Back to cited text no. 17
    
18.
Yamamura Y, Ito S, Mochizuki Y, Nakanishi H, Tatematsu M, Kodera Y. Distribution of free cancer cells in the abdominal cavity suggests limitations of bursectomy as an essential component of radical surgery for gastric carcinoma. Gastric Cancer 2007;10:24-8.  Back to cited text no. 18
    
19.
Gui-Chao L, Zhen Z, Xue-Jun M, Xiao-Li Y, Gang C, Wei-Gang H. The value of patterns of loco-regional recurrence of gastric cancer after curative resection and efficacy of radiation therapy for cancer recurrence in target definition in postoperative radiotherapy. Tumor 2012;32:794-9.  Back to cited text no. 19
    
20.
Takeyoshi I, Ohwada S, Ogawa T, Kawashima Y, Ohya T, Kawate S, et al. The resection of non-hepatic intraabdominal recurrence of gastric cancer. Hepatogastroenterology 2000;47:1479-81.  Back to cited text no. 20
    


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