What are the considerations for undergoing a bursectomy?

Considerations for Bursectomy in Gastric Cancer Treatment

Bursectomy should be avoided in T1/T2 gastric tumors due to risk of pancreatic injury and lack of survival benefit, but may be considered for tumors penetrating the serosa of the posterior gastric wall (T3/T4a) to remove potential microscopic tumor deposits in the lesser sac. 1

Definition and Purpose

• Bursectomy is the removal of the inner peritoneal surface of the bursa omentalis (omental bursa), performed with the aim of removing microscopic tumor deposits in the lesser sac 1
• It has historically been considered part of radical surgery for gastric carcinoma in Japan, particularly for serosa-positive gastric cancer 2

Evidence-Based Recommendations

Tumor Stage Considerations

• Early-stage tumors (T1/T2): Bursectomy should be avoided to prevent injury to the pancreas and adjacent blood vessels 1
• Advanced tumors (T3/T4a): May be considered for tumors penetrating the serosa of the posterior gastric wall 1
• A small-scale randomized controlled trial suggested a survival benefit for bursectomy in T3/T4a tumors, but more definitive evidence was needed 1

Recent Evidence on Efficacy

• The JCOG1001 large-scale multi-institutional randomized trial was conducted to address the efficacy of bursectomy 1, 3
• Final results after 5-year follow-up showed no survival benefit:
  • 5-year overall survival rates: 74.9% in bursectomy group vs. 76.5% in omentectomy-alone group 3
  • Bursectomy did not decrease peritoneal recurrence (12.1% vs. 12.3%) 3
  • The adjusted hazard ratio for death in the bursectomy group was 1.03 (95% CI 0.83 to 1.27) 3

Surgical Complications

• Bursectomy is associated with a significantly higher incidence of Clavien-Dindo grade III-IV intra-abdominal abscess compared to omentectomy alone (5.5% vs. 2.5%) 3
• Risk of injury to the pancreas and adjacent blood vessels, especially in T1/T2 tumors 1

Technical Considerations

• Can be performed during both open and laparoscopic gastrectomy, though laparoscopic bursectomy is technically more challenging 2
• Requires expertise in advanced gastric cancer surgery 2

Rationale for Limited Use

• Cancer cells disseminated into the bursa rarely remain restricted to this cavity without migrating into the free abdominal cavity 4
• In a study of peritoneal washes, only 2 out of 136 patients had cancer cells exclusively in the omental bursa 4
• The Italian Research Group for Gastric Cancer (GIRCG) acknowledges that bursectomy may be performed when the posterior gastric wall serosa is infiltrated, but notes the limited evidence 1

Current Recommendation

• Based on the JCOG1001 trial results, bursectomy is not recommended as a standard procedure for cT3-T4a gastric cancer in D2 gastrectomy 3
• The procedure should be reserved for selected cases where there is high suspicion of microscopic tumor deposits in the lesser sac 1
• Multivariable analysis from JCOG1001 identified several independent predictors of poor overall survival (age >65 years, tumor in lower third/posterior wall, macroscopic type 3/5, total gastrectomy, and cT4a), but omentectomy alone was not associated with worse outcomes 3

Special Considerations

• For patients with tumors penetrating the serosa of the posterior gastric wall, the decision to perform bursectomy should be made by an experienced surgeon based on individual tumor characteristics 1
• The potential marginal benefit in specific cases must be weighed against the increased risk of complications 3, 5