Totally Laparoscopic versus Open Gastrectomy for Gastric Cancer: a Matched Pair Analysis.

Background: Laparoscopic gastrectomy has been established for treatment of early gastric cancer (EGC) especially in Eastern Asian countries. Currently, it still needs evaluation for advanced gastric cancer (AGC, T ≥ 2). Difficulty is how far Asian study data are valid for western conditions.

Methods: Out of 502 patients who underwent gastric cancer surgery between 2003 and 2016 at Klinikum Suedstadt Rostock 90 patients were selected for a retrospective study to compare totally laparoscopic D2-gastrectomy (LG, n = 45) with open D2-gastrectomy (OG, n = 45). The groups were matched by age, gender and tumour stage (TNM).

Results: Average age was 62.9 years (33 - 83), 42.2% were female. There were no differences between both study groups concerning BMI, ECOG and comorbidities. Amounts of EGC and AGC were 35.5% and 64.4% in LG, 28.9% and 71.0% in OG (p = 0.931). In LG-group 53.3% of the patients and in OG-group 51.1% of the patients were nodal negative (p = 0.802). 31.1% of patients in LG and in 33.3% in OG (p = 0.821) undergone perioperative chemotherapy. Total gastrectomy was performed in 73.3% in LG and 82.2% in OG, subtotal resections were done in 26.7% in LG and 17.8% in OG (p = 0.310). Resection free margins (R0) were recognized in 97.8% of the patients in both groups, and for EGC in all cases (p = 0.928). Total numbers of retrieved lymph nodes were significant higher in LG (33.1, 17 - 72) than in OG (28.2, 14 - 57). A significant longer operation time was noticed for laparoscopic gastrectomy in contrast to open surgery (+ 43.0 ± 27.2 min, p = 0.0054). Overall morbidity in OG (44.4%) was twice as high as in LG (22.2%, p < 0.05) due to lower rate of minor complications (Clavien I - II) in LG (LG vs. OG: 13.3% vs. 37.8%, p = 0.0078). For major complications (Clavien ≥ III) no difference between both groups was detected (LG vs. OG: 8.8% vs. 6.6%, p = 0.69). LG showed a significant faster postoperative recovery with earlier oral fluid intake (LG vs. OG: 25.9 h vs. 46.2 h) and shorter time to first flatus (LG vs. OG: 81.6 vs. 102.6 h). Patients after LG were earlier out of bed (LG vs. OG: 69.7 h vs. 108.7 h) and also hospital stay was significantly shorter (11.9 days in LG vs. 16.3 days in OG, p = 0.037). 30- and 90-days mortality was equal for LG and OG (0 and 2.2% per group). After a median follow up of 51.9 month (1 - 117) there were similar results for 3- and 5-year overall survival (OS for LG: 75.6% and 64.6% vs. OG: 68.9% and 64.6%, p = 0.446). Also no differences for 3- and 5-year OS were detected concerning patients without lymph node metastases (LG: 91.7% and 83.4% vs. OG: 91.3% and 78.3%, p = 0.658) or lymph node positive patients (LG: 47.6% and 38.1% vs. OG: 40.9% and 31.8%, p = 0.665).

Conclusion: Despite western conditions laparoscopic D2 gastrectomy is certainly a save and feasibly approach for surgical therapy of EGC and AGC with low morbidity and mortality, and faster postoperative recovery. The oncologic outcome seems to be equivalent to open surgery.