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treatment has gained popularity in the last few decades, as it potentially results in a better outcome
regarding morbidity and survival. In 1994, a laparoscopic distal gastrectomy (LDG) for early gastric
[3]
cancer was reported for the first time . A few years later, a series of laparoscopic total gastrectomy’s (LTG)
[4]
with D1 and D2 lymph node dissection was published . Since then, experience in laparoscopic surgery
has improved with time allowing both distal gastrectomy and total gastrectomy to be performed more
frequently worldwide. This report outlines the current state of LG for gastric cancer and its future outlook.

LDG FOR GASTRIC CANCER
[3]
Since the report by Kitano et al. in 1994, LDG has been investigated intensively, predominately in the
Far East. A large Korean case control study which compared both LDG and LTG with OG showed no
[5]
differences in survival, morbidity and mortality . Several large randomised controlled trials (RCTs) have
been performed, mainly in Asia. The Chinese CLASS-01 trial compared LDG with open distal gastrectomy
[6]
(ODG) for patients with early stage gastric cancer [T2-4 N0-3, M0 (stage 1 gastric cancer) ]. Three-
year disease-free survival was 76.5% in the laparoscopic group compared with 77.8% in the open group
[1-sided 97.5%CI: (-6.5% to ∞)]. In addition, three-year overall survival (OS) rate was 83.1% in patients who
underwent a LDG compared with 85.2% in the ODG group (HR 1.19; 95%CI: 0.87-1.64; P = 0.28). About
40% of the patients in both treatment groups received adjuvant chemotherapy. The Korean KLASS-01
trial compared LDG with ODG for patients with early stage gastric cancer [T1/2, N0/1, M0 (stage 1 gastric
[7]
cancer) ]. The 5-year OS was 94.2% in the laparoscopic group and 93.3% in the open group (P = 0.64). In
addition, cancer-specific survival rate was 97.1% in patients who underwent a LDG compared with 97.2% in
[8]
the ODG group (P = 0.91). Earlier, the short-term outcomes of the KLASS-01 trial were published . Patients
who underwent a LDG had a reduced overall complication rate (LDG vs. ODG; 13.0% vs. 19.9%; P = 0.001),
reduced length of stay (LOS) (LDG vs. ODG; 7.1 ± 3.1 vs. 7.9 ± 4.1; P < 0.001), and a reduced lymph node yield
(LDG vs. ODG; 40.5 ± 15.3 vs. 43.7 ± 15.7; P < 0.001). In addition, post-operative mortality was equal. The
[9]
Japanese JCOG0912, which compares LDG with ODG, only reported their short term outcomes . This
study reported that a laparoscopic approach resulted in a longer operation time (LDG vs. ODG; median
278 min vs. 194 min; P < 0.001) and reduced blood loss (LDG vs. ODG; median 38 mL vs. 115 mL; P <
0.001). In addition, no differences were reported in mortality and lymph node yield. These studies show that
a laparoscopic approach for early stage gastric cancer is safe and reduces the complication rate. However,
we will have to wait for the long-term data to interpret the effect of a laparoscopic approach on long-term
oncological outcome.

A meta-analysis has compared LDG with ODG including twenty-five studies in the analysis. They reported
that a LDG was associated with longer operative times [weighted mean differences (WMD - 48.3 min; P <
0.001)], reduced post-operative complications (OR 0.49; P = 0.002), reduced blood loss (WMD - 118.9 mL; P
< 0.001), as well as reduced LOS (WMD - 3.6 days; P < 0.001) . However, patients in the open group had a
[10]
significant higher lymph node yield (WMD 3.9; P < 0.001). The impact of this reduced lymph node yield on
oncological and long-term outcome is unknown. The longer operating time for LDG may be because some
surgeons are still on the learning curve. Overall these studies demonstrate that short-term outcomes of
LDG for patients with gastric cancer are comparable to ODG.

LTG FOR GASTRIC CANCER
The laparoscopic approach for LTG has also gained in popularity worldwide since the first series was
reported in 1999 . A meta-analysis reviewed the short-term outcomes of LTG compared with OTG in
[4]
[11]
patients with gastric cancer . In eight selected studies, LTG was associated with a significant reduction of
intraoperative blood loss (WMD - 227.6 mL; 95%CI: 144.3-310.9; P < 0.001), reduced LOS (WMD - 4.0 days;
95%CI: 1.4-6.5; P < 0.001) and reduced postoperative complications (RR 0.51; 95%CI: 0.33-0.77). However, a
prolonged operation time was seen in patients who underwent a LTG (WMD - 55.5 min; 95%CI: 24.8-86.2;