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Page 4 of 9 van den Berg et al. Mini-invasive Surg 2019;3:23 I http://dx.doi.org/10.20517/2574-1225.2019.07

complications were similar, patients were more likely to die when they experienced complications following
OG.

A systematic review of 16 non-RCTs of anastomotic complications following LTG vs. OTG did not find any
statistical difference in the incidence of anastomotic leakage, 3.0% vs. 2.1% respectively (OR 1.42, 95%CI:
[20]
0.86-2.33; P = 0.17) . The incidence of anastomotic stenosis was also not significantly different between
groups, 3.2% vs. 2.7% following LTG and OTG respectively (OR 1.55, 95%CI: 0.94-2.54; P = 0.08). When the
LTG was classified into six categories for the various anastomotic techniques, review of the case studies
demonstrated a similar anastomotic leak rate (1.1%-3.2%), however the incidence of stenosis was relatively
TM
high when the OrVil device was used (8.8%) compared with other procedures (1.0%-3.6%).

LONG TERM ONCOLOGICAL OUTCOMES AND MORBIDITY
So far, there are no publications of randomised control trials comparing LG with OG which report long
term survival data. However, long term survival has been assessed in a meta-analysis looking at 5-year
[21]
results, for OS, recurrence or gastric cancer related death . In this analysis, 23 studies with a total of 7336
patients who underwent a distal or total gastrectomy were included. Excluding the studies that didn’t have
well balanced groups, they reported no differences between LG and OG as 5-year OS (OR 1.07, 95%CI: 0.90-
1.28; P = 0.45), recurrence (OR 0.83, 95%CI: 0.68-1.02; P = 0.08), and gastric cancer-related death (OR 0.86,
95%CI: 0.65-1.13; P = 0.28) rates were similar. They conclude that long term results of LG are comparable to
open surgery for both early and advanced gastric cancer.

Large propensity matched cohort studies have been performed to assess the long-term outcomes between
OG and LG for advanced gastric cancer to achieve an immediate assessment whilst we await the results
of RCTs. Li et al. matched 459 and 856 patients undergoing laparoscopic or OG (both distal and total)
[22]
respectively for advanced gastric cancer with D2 lymph node resection. No significant difference was
identified in the 5-year OS (52.0% and 53.4%; P = 0.805) and disease-free survival (46.8% vs. 47.3%; P =
0.963) between the laparoscopic and open groups. Stratified assessment also did not identify any differences
according to tumour stage. The operation method was not an independent prognostic factor for OS or
disease-free survival. In addition, the recurrence pattern was similar between the laparoscopic and OG
groups.

Another propensity matched cohort study, the LOC-A study, matched 610 cases with advanced gastric
[23]
cancer (stage 2/3) who underwent a laparoscopic or open distal, proximal or total gastrectomy . No
significant differences in 5-year survival or recurrence was found. Five-year survival for OG was 53.0%
compared to 54.2% following LG. In addition, the recurrence rate was 30.8% and 29.8% respectively. High
risk patients have also been assessed in a further propensity matched cohort study comparing LG with
[24]
OG . The patients underwent a distal or total gastrectomy. High risk patients were deemed to have at
least one of: age > 80 years, BMI > 30 kg/m , ASA grade ≥ 3, or clinical T stage 4. After matching, each
2
group had 341 patients with no difference in clinico-pathological data between the open and laparoscopic
groups. Operating time (181.70 min vs. 266.71 min; P < 0.001) and blood loss (68.11 mL vs. 225.54 mL; P <
0.001) were significantly lower in the LG group, whilst postoperative complications occurred in 11.4% and
18.5%, in the LG and OG group respectively (P = 0.010). Therefore, laparoscopic surgery was a significant
protective factor against post-operative complications (P = 0.019). In addition, the number of risk factors
present was an independent risk factor for post-operative complications (P = 0.021). Again, the 5-year OS
rate was similar between the LG and OG groups (55.0% vs. 52.0%; P = 0.086).

ENHANCED RECOVERY AFTER SURGERY
[25]
Enhanced recovery after surgery (ERAS) program has been described for the first time in the nineties .
Since then, the success of programs has been described in various fields of surgery, including both open