Author:

Karol Polom

Abstract

For many years, gastric cancer was the most common malignancy worldwide. However, advances in understanding its causes and implementing preventive measures have led to a decline in incidence and mortality in recent decades. Europe was pivotal in pioneering the early surgical approaches to this previously untreated disease. Although initial results were often unsuccessful, these early surgeons from the 19th and 20th centuries transformed the treatment of gastric cancer, setting the stage for a continuous journey toward curing this disease. This paper provides a brief overview of the history of gastric cancer surgery from a European perspective.

History of Gastric Cancer Surgery

The history of gastric cancer treatment highlights significant differences between Eastern and Western treatment strategies.

The origins of gastric cancer surgery lie in Europe, with initial publications and advancements emerging from this continent. Over time, American and Asian contributions have also become crucial, particularly due to the high incidence of gastric cancer in East Asia.

Modern gastric cancer treatment requires a multidisciplinary approach. Personalized treatment for this malignancy now involves advanced diagnostic and staging technologies and minimally invasive techniques, as well as complex multimodal strategies for the most complex cases. The evolution from the "bigger is better" approach to modern, tailored treatments illustrates the progress in gastric cancer surgery over the centuries.

Gastric cancer remains one of the most common cancers globally. Decades ago, it was the leading cancer by incidence. However, the identification of Helicobacter pylori as a major carcinogen and subsequent dietary changes have led to a decline in new cases. In Europe, the incidence is notably high in Eastern Europe, while Northern Europe shows a relatively low incidence [Ferlay 2019, Sung 2021].

The earliest description of gastric cancer was by Hippocrates, the father of medicine, in Ancient Greece in the 4th century BC [Gourevitch 1995]. A significant advancement came in 1839 when French anatomist Jean Cruveilhier described cancerous gastric ulcers [Hindmarsh 1998]. In 1868 Adolf Kussmaul, the father of endoscopy, observed the stomach from the inside using a gastroscope, and in 1883 German inventor Hugo Krockner and American Samuel Melzer developed an esophageal manometer.

Gastric Cancer Surgery

The official history of gastric cancer surgery began in France. On April 9, 1879, Jules-Émile Péan performed a partial gastrectomy for gastric cancer. After a resection of the distal part of the stomach, the remaining section was anastomosed with the small intestine. The patient died on the fifth postoperative day. On November 16, 1880, Polish surgeon Ludwik Rydygier attempted a gastric cancer surgery, but the patient died on the postoperative night. Despite the failure, Rydygier's detailed publications contributed significantly to the development of future surgical treatments.

On January 22, 1881, in Vienna, Christian Albert Theodor Billroth performed an operation on 43-year-old Therese Heller, who had distal stomach stenosis due to cancer. The patient was discharged after four weeks but died four months later from liver metastases. Billroth initially performed a gastroduodenal anastomosis, which he later modified to a more radical Billroth II procedure, where the remaining stomach was anastomosed with the small intestine. Despite the high mortality rate, with a 55.2% mortality in 29 cases (1878-1890), Billroth's techniques were foundational. His successor, Mikulicz, a Polish-German surgeon in Wroclaw, reported a mortality rate of 27.8% in 18 cases between 1882-1895 [Mikulicz 1896].

In 1897, Swiss surgeon Karl Schlatter performed a total gastrectomy with esophagojejunostomy for reconstruction in Zurich. The patient died after 14 months due to recurrence. Mikulicz was also the first to perform cardiectomy [Olch 1960] and described four patterns of gastric cancer progression: local, lymphatic, hematogenous, and peritoneal dissemination. He emphasized the importance of lymph node dissection for curative intent [Mikulicz 1889]. In 1903, Mikulicz reported a 27.5% mortality rate in cases without pancreatic infiltration and 70% with additional pancreatic resection.

The next significant advancement in the European chapter of gastric cancer surgery came from British surgeon Groves in 1910, who demonstrated the necessity of omentum resection for effective lymph node dissection [Groves 1910]. This led to the incorporation of bursectomy and omentectomy into surgical procedures. Major advances in gastric cancer surgery and especially the implementation of laparoscopy and robotic approaches were later introduced in Asian countries.

Clinical trials evaluating the effectiveness of Japanese-style D2 lymphadenectomy were conducted in the UK and Netherlands. The ST01 trial by the Medical Research Council and a Dutch trial showed a high rate of postoperative complications and deaths and no additional survival benefit from D2 lymphadenectomy [Cushieri 1999; Bonnekamp 1999]. However, an Italian Gastric Cancer Study Group RCT demonstrated the benefit of D2 lymphadenectomy in patients with lymph node metastases [Degiuli 2014]. A 15-year follow-up of the Dutch trial confirmed a significant survival benefit from D2 lymphadenectomy, leading to its adoption as a standard practice [Songun 2010].

The first RCT comparing subtotal and total gastrectomy for gastric cancer, conducted in France in 1989, found no survival benefit for total gastrectomy over subtotal [Gouzi 1989]. Similar findings were reported by the Italian Gastrointestinal Tumor Study Group in 1999 [Bozzetti 1999]. The LOGICA trial, a Phase II RCT, demonstrated the safety of laparoscopic approaches with similar hospital stays compared to open surgery [van der Veen 2021]. Interestingly, the STOMACH trial from the Netherlands showed no significant difference in the number of dissected lymph nodes between open and laparoscopic total gastrectomy after neoadjuvant treatment [van der Wielen 2020].

Treatment for gastric cancer has evolved over time. Currently, a multimodal approach is recommended and varies by region. Other oncological options are considered before surgery to optimize the results in the treatment of this malignancy. In Europe, most advanced gastric cancer patients receive neoadjuvant chemotherapy. The efficacy of this approach was validated by two European trials: the MAGIC trial, which used three cycles of preoperative and postoperative chemotherapy (epirubicin, cisplatin, and 5-fluorouracil), and the FNLCC/FFCD 9703 trial, which used two or three cycles of preoperative cisplatin and 5-fluorouracil, continuing with postoperative chemotherapy if a response was observed [Cunningham 2008, Ychou 2011].

The history of gastric cancer treatment began in Europe, where pioneering surgeons made groundbreaking contributions that advanced scientific knowledge and treatment standards. Today, European cancer organizations and international scientific groups continue to drive progress in gastric cancer treatment. Pan-European collaboration may be key to improving and tailoring treatment to achieve better outcomes in curing this cancer.

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