Dear Editor,
We read with great interest the prospective study by Washio et al. on laparoscopic and endoscopic cooperative surgery (LECS) for elderly patients with gastric cancer who declined or were considered poor candidates for standard gastrectomy [1]. The attempt to offer a function‐preserving option using the inverted crown method, together with a systematic assessment of body weight, lean body mass, and quality of life (QOL), is a clinically relevant approach in a population in which nonintervention is often the default. However, certain methodological and clinical aspects warrant closer examination.
Although the procedure is framed as an “alternative,” 80% of tumors were clinically T1 and 90% were clinically node‐negative, yet lymph nodes retrieved incidentally with the full‐thickness specimen contained metastases in five of 11 patients. Without a planned D1 or D1+ lymphadenectomy, local gastric control cannot reliably translate into disease control for node‐positive patients, and the encouraging 1‐ and 3‐year outcomes will partly mirror tumor biology rather than the efficacy of LECS itself [2]. This is particularly relevant for undifferentiated or upstaged lesions, for which margin‐negative resection alone is unlikely to be sufficient; such cases may need to be positioned as symptom‐preventive rather than disease‐eradicating indications.
The inclusion pathway combined patient refusal, perioperative risk, and clinical frailty; however, the Eastern Cooperative Oncology Group (ECOG) performance status was 0–1 in almost all participants, and the American Society of Anesthesiologists Physical Status (ASA‐PS) was II in most. This profile suggests a fitter‐than‐average elderly cohort. At the same time, the median operative time was 312 min and the postoperative stay was 7 days, both substantial exposures for octogenarians; in a genuinely frail population, these perioperative demands could offset the intended minimally invasive advantage [3].
The inference on postoperative QOL was based on the Postgastrectomy Syndrome Assessment Scale‐45 (PGSAS‐45), which was designed for patients after distal or total gastrectomy [4]. Most symptom domains changed little between 1 and 3 months, and the improvements (meal amount, meal quality, and physical component summary) were modest and early. When viewed together with the intensive surveillance schedule of repeated computed tomography, upper gastrointestinal endoscopy, and serial body composition measurements, the net functional gain for very old patients becomes less certain.
In summary, LECS using the inverted crown method appears technically safe and organ‐preserving for elderly patients who decline standard gastrectomy, but its use may be most appropriate in carefully selected patients in whom prevention of tumor‐related events and maintenance of oral intake are prioritized over radicality. Future evaluations would benefit from geriatric assessment‐based selection, an LECS‐specific patient‐reported outcome framework, and a comparison with best supportive or endoscopic management to define the true clinical niche of this procedure.
Author Contributions
Shyam Sundar Sah: conceptualization, methodology, writing – original draft, writing – review and editing. Abhishek Kumbhalwar: validation, supervision, project administration, writing – original draft, writing – review and editing.
Funding
No funding was received for this study.
Ethics Statement
The authors have nothing to report.
Consent
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Linked Articles
Laparoscopic and endoscopic cooperative surgery for gastric cancer as an alternative treatment in elderly patients: a prospective observational study, https://doi.org/10.1002/ags3.70108.
Acknowledgments
Generative AI tools, including Paperpal and ChatGPT 5, were utilized solely for language, grammar, and stylistic refinement. These tools had no role in the conceptualization, data analysis, interpretation of results, or substantive content development of this manuscript. All intellectual contributions, data analysis, and scientific interpretations remain the sole work of the authors. The final content was critically reviewed and edited to ensure accuracy and originality. The authors take full responsibility for the accuracy, originality, and integrity of the work presented.
Data Availability Statement
Data sharing is not applicable to this article, as no data were generated or analyzed in this study.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data sharing is not applicable to this article, as no data were generated or analyzed in this study.