Laparoscopic gastrectomy comparable to open gastrectomy for gastric cancer

Laparoscopic gastrectomy (LG) offers comparable outcomes to open gastrectomy (OG) even in patients with advanced tumours, results of a recent study involving 294 gastric cancer patients in Hong Kong have shown.

“This is the first report assessing the safety and efficacy of LG for gastric cancer in a tertiary referral centre in Hong Kong. The results showed no significant differences in postoperative complications and mortality between LG and OG, supporting the use of LG for patients with gastric cancer, including those with advanced cancer,” the researchers noted. [Surg Oncol 2020;35:14-21]

The retrospective longitudinal study included gastric cancer patients with histologically confirmed adenocarcinoma without distant metastasis, who underwent primary radical gastrectomy with either LG (n=157; male, 66.2 percent) or OG (n=137; male, 73.7 percent) in Queen Mary Hospital between January 2008 and December 2015. Propensity score (PS) matching was done to reduce the effect of selection bias on the surgical approach and potential confounding factors.

Result showed higher rates of limited lymphadenectomy (D0, D1, D1+) with OG than LG (31.4 percent vs 7.6 percent; p<0.66), given that D1+ lymphadenectomy was performed as the standard operating procedure for proximal gastrectomy and OG was the treatment preference for difficult and unfavourable conditions, such as adhesions from previous surgery. Significantly more combined resections, which included the gallbladder, transverse colon or mesentery, were performed in patients undergoing OG vs LG (38 patients vs 4 patients; 27.5 percent vs 2.5 percent; p<0.01).

Although the mean surgical time was significantly increased with LG vs OG (294.7 minutes vs 231.8 minutes; p<0.01) in the PS-matched cohort, LG was associated with a significant reduction in mean estimated blood loss (191.6 mL vs 351.0 mL; p=0.01). Other surgical outcomes, including the need for intraoperative blood transfusion, resection margins, number of lymph nodes examined and duration of postoperative hospital stay, were comparable between groups.

Patients who underwent OG had more intraoperative complications, such as spleen laceration, than those who underwent LG (9.3 percent vs 0 percent; p=0.06), but rates of postoperative complications were not significantly different between the groups, 40.7 percent vs 35.2 percent; p=0.69). Rates of 30-day and 90-day mortality were similar between the OG and LG groups (30-day mortality, 0 percent vs 0 percent) (90-day mortality, 3.7 percent vs 1.9 percent; p=1.00), with comparable Clavien-Dindo gradings for surgical complications (p=0.58).

Significant differences in pathological characteristics, in terms of tumour size, lymphovascular invasion, pT stage, pN stage, surgical margins and use of adjuvant chemotherapy, were observed between the LG and OG groups (all p<0.05).

At a median follow-up of 48 months, comparable rates of 3-year overall survival (OS) and disease-free survival (DFS) were reported with LG vs OG (3-year OS rate, 64.8 percent vs 55.6 percent; p=0.34) (3-year DFS rate, 61.1 percent vs 55.6 percent; p=0.51). The surgical approach (ie, OG vs LG) had no influence on patients’ survival outcomes. 

Disease recurrence within 3 years of surgery occurred in 20 patients in the OG group and 11 patients in the LG group, respectively, with a significantly greater number of OG- vs LG-treated patients having peritoneal recurrences within 3 years of surgery (15 vs 2; p<0.01).

Despite the high volume of surgical cases in Hong Kong every year, only 60–70 gastrectomies are performed annually. In Queen Mary Hospital, LG is mostly indicated in cases of distal gastrectomy, patients with earlier-disease stage, and those without combined resection of other organs.