Page 184 - Read Online

van den Berg et al. Mini-invasive Surg 2019;3:23 I http://dx.doi.org/10.20517/2574-1225.2019.07 Page 3 of 9

P < 0.001). In addition, there was no difference in the in-hospital mortality between both groups. A further
meta-analysis for LTG was performed which reviewed 10 retrospective cohort studies and 2 case-controlled
[12]
studies . A laparoscopic approach for gastric cancer resulted in reduced postoperative complications
(OR 0.66; P = 0.02), reduced blood loss (WMD - 160.70 mL; P < 0.00001), as well as reduced LOS (WMD -
2.43 days; P = 0.0002). In addition, there was no significant difference in mortality (OR 0.60, P = 0.52), lymph
node yield (WMD - 2.30; P = 0.06), radicality or negative resection margin status. However, again it was
observed that a minimally invasive approach resulted in a significantly prolonged operation time (WMD -
48.06 min; P < 0.00001).

A case control study which compared laparoscopic with OG (for both distal and total gastrectomy)
showed similar results in line with the meta-analysis. A laparoscopic approach resulted in reduced blood
[13]
loss, reduced LOS, reduced minor complications and a prolonged length of operation time . However,
interestingly this study also demonstrated that a laparoscopic approach for gastric cancer resulted in a
significant increased likelihood of receiving and completing the course of adjuvant therapy. In the well-
known MAGIC trial only 49.5% of the patients who successfully completed neo-adjuvant chemotherapy
[14]
and surgery also completed 3 cycles of adjuvant chemotherapy . As adjuvant treatment is critically
important for patients with (advanced) gastric cancer this may demonstrate an important benefit of a
laparoscopic approach. A propensity scored matched analysis compared LG to OG during the introduction
[15]
of LG in the Netherlands . Analyses in 884 patients showed less wound complications (2% vs. 5%, P =
0.006) and less chyle leakage (1% vs. 4%, P = 0.004) in patients who underwent LG. However, there was no
difference in overall postoperative morbidity or anastomotic leakage.

Overall these studies show that LTG is feasible and safe. Further research in the form of RCTs are
warranted to confirm short term morbidity and quality of resection, but in particular provide the best data
to evaluate the long-term oncological outcomes. So far, most of the studies are conducted in the Far East.
[16]
A RCT which compares LTG gastrectomy with OTG is currently ongoing . The primary endpoint of this
study is to evaluate the effect of surgical approach on morbidity and mortality in patients with T1/2, N0/1,
M0 (stage 1) gastric cancer. More recently, a Korean RCT comparing open with LTG for advanced gastric
cancer has started (KLASS-06). However, results from the Far East cannot be easily translated to the
Western population. This is mainly due to the different population and body mass index, a less advanced
stage of gastric cancer in Asia, and a much lower utilization of (neo)-adjuvant chemotherapy. In Europe
two RCTs are ongoing, the STOMACH trial and the LOGICA trial [17,18] . Both multicentre randomised
trials study the effect of LG with OG in patients with more advanced gastric cancer (T1-3, N0-1, M0) in the
Western population. Patients included in these studies predominantly received neoadjuvant chemotherapy.
Primary endpoints in these trials are the quality of the oncologic resection and postoperative complications.
Recently, preliminary results of these two trials were presented at the International Gastric Cancer Congress
2019. Laparoscopic and OG resulted in comparable oncological outcomes, and comparable morbidity and
mortality. Overall, final results of these studies will provide more information on which surgical technique
is optimal for treatment of resectable gastric cancer.

COMPLICATIONS FOLLOWING LG
Gastric cancer surgery is associated with high morbidity. One of the benefits of a laparoscopic approach is
reducing morbidity. A propensity matched analysis assessed complications in 4124 patients who underwent
[19]
a LG or OG, of whom 627 patients developed complications . No significant differences were found
in overall complications (14.2% vs. 16.5 %; P = 0.093). However, hospital mortality was reduced in the
LG group (0.3% vs. 1.2%; P = 0.004) as was failure to rescue rates (2.1% vs. 7.6%; P = 0.008). Multivariate
analysis showed that older age, tumour location, TNM stage, extent of gastric resection, operative time
and operative blood loss were adverse risk factors for complications. They concluded that whilst overall