Abstract
Simple SummaryGastric resection with D2 lymphadenectomy is considered the gold standard for the treatment of both advanced and early gastric cancer with lymph node metastasis. The performance of D2 lymphadenectomy is technically challenging and represents a key factor in improving patients’ survival. For these reasons, the execution of gastrectomy with D2 lymphadenectomy using the traditional open surgical technique still represents the most widespread approach and, based on current international guidelines, the indication for laparoscopic surgery is limited to early gastric cancer that does not require a D2 lymphadenectomy. The present study aimed to investigate the use of laparoscopic versus open surgical approaches in performing gastrectomy with D2 lymphadenectomy for cancer in terms of intraoperative and postoperative outcomes and long-term survival. The study was conducted using the data collected in the International study group on Minimally Invasive surgery for Gastric Cancer (IMIGASTRIC) international database.Background: The laparoscopic approach in gastric cancer surgery is being increasingly adopted worldwide. However, studies focusing specifically on laparoscopic gastrectomy with D2 lymphadenectomy are still lacking in the literature. This retrospective study aimed to compare the short-term and long-term outcomes of laparoscopic versus open gastrectomy with D2 lymphadenectomy for gastric cancer. Methods: The protocol-based, international IMIGASTRIC (International study group on Minimally Invasive surgery for Gastric Cancer) registry was queried to retrieve data on patients undergoing laparoscopic or open gastrectomy with D2 lymphadenectomy for gastric cancer with curative intent from January 2000 to December 2014. Eleven predefined, demographical, clinical, and pathological variables were used to conduct a 1:1 propensity score matching (PSM) analysis to investigate intraoperative and recovery outcomes, complications, pathological findings, and survival data between the two groups. Predictive factors of long-term survival were also assessed. Results: A total of 3033 patients from 14 participating institutions were selected from the IMIGASTRIC database. After 1:1 PSM, a total of 1248 patients, 624 in the laparoscopic group and 624 in the open group, were matched and included in the final analysis. The total operative time (median 180 versus 240 min, p < 0.0001) and the length of the postoperative hospital stay (median 10 versus 14.8 days, p < 0.0001) were longer in the open group than in the laparoscopic group. The conversion to open rate was 1.9%. The proportion of patients with in-hospital complications was higher in the open group (21.3% versus 15.1%, p = 0.004). The median number of harvested lymph nodes was higher in the laparoscopic approach (median 32 versus 28, p < 0.0001), and the proportion of positive resection margins was higher (p = 0.021) in the open group (5.9%) than in the laparoscopic group (3.2%). There was no significant difference between the groups in five-year overall survival rates (77.4% laparoscopic versus 75.2% open, p = 0.229). Conclusion: The adoption of the laparoscopic approach for gastric resection with D2 lymphadenectomy shortened the length of hospital stay and reduced postoperative complications with respect to the open approach. The five-year overall survival rate after laparoscopy was comparable to that for patients who underwent open D2 resection. The types of surgical approaches are not independent predictive factors for five-year overall survival.
Highlights
By adopting the case-matched study design, we were able to compare clinical, pathological, and survival outcomes in a total of 1248 patients, 624 in each study group, who were selected from the IMIGASTRIC registry according to 11 predefined covariates to control for possible confounders
Our study indicates that the laparoscopic approach for total or distal gastrectomy with D2 lymphadenectomy is capable of significantly reducing, with respect to the open approach, the total operating time, the length of postoperative hospital stay as well as the number of postoperative in-hospital complications (142 versus 173, respectively, p = 0.043) and the proportion of patients with at least one in-hospital complication
We can explain this wide variation by the fact that a large proportion of patients included in our analysis were treated in selected, very high volume centers dedicated to gastric cancer treatment that are mainly located in the east, in China
Summary
Gastric cancer is the fifth most common malignancy worldwide and the third leading cause of cancer death globally [1].Gastrectomy with adequate lymphadenectomy still represents the treatment of choice to obtain radical resection and achieve better survival outcomes in the case of resectable gastric cancer.Based on the current international guidelines, D2 lymphadenectomy should be performed in the event of T2-4aN0-3M0 stage gastric cancer [2].The laparoscopic approach in gastric cancer surgery was first described in 1994 to perform distal gastrectomy for early gastric cancer [3].The current Japanese guidelines for gastric cancer treatments consider laparoscopic surgery as an option to treat cStage I cancer that is resectable with a distal gastrectomy and indicate that, for advanced gastric cancer, some concern still exists based on the available evidence in the literature, mainly concerning the survival endpoints with respect to the open approach, for total gastrectomy [2].primarily thanks to the well-established benefits of laparoscopy in early postoperative outcomes, the laparoscopic approach is being increasingly adopted for the performance of gastrectomy with D2 lymphadenectomy [4]. The laparoscopic approach in gastric cancer surgery was first described in 1994 to perform distal gastrectomy for early gastric cancer [3]. The current Japanese guidelines for gastric cancer treatments consider laparoscopic surgery as an option to treat cStage I cancer that is resectable with a distal gastrectomy and indicate that, for advanced gastric cancer, some concern still exists based on the available evidence in the literature, mainly concerning the survival endpoints with respect to the open approach, for total gastrectomy [2]. Methods: The protocol-based, international IMIGASTRIC (International study group on Minimally Invasive surgery for Gastric Cancer) registry was queried to retrieve data on patients undergoing laparoscopic or open gastrectomy with D2 lymphadenectomy for gastric cancer with curative intent from January 2000 to December 2014. The total operative time (median versus 240 min, p < 0.0001) and the length of the postoperative hospital stay
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