Owing to the aggressive disease, old age in the majority of cases, poor nutrition, extreme radical dissection, and surgical traumas, patients with locally advanced GC are prone to prolonged hospital stay, postoperative morbidity, increased financial burden, and even a high risk of postoperative mortality 35. Thus, in patients with GC, surgeons must be careful when choosing the treatment strategy 35. This concept makes LG the fastest growing minimally invasive procedure for patients with GC 36.
Several trials have indicated that LG could provide smaller incisions, reduced bleeding, and decreased surgical stress 37,38. Despite the great advances in this technique and its impact on oncological outcomes, however, LG has some issues, such as decreased intraoperative compliance of lung owing to the establishment of artificial pneumoperitoneum as well as the relatively long time required for this technique 39. Some researchers have therefore suggested using neoadjuvant chemotherapy before LG or OG because the application may help prevent an unnecessary procedure by reducing the size of the tumor and making the resection of R0 easier. In addition, micrometastatic tumor cell eradication can begin at an early stage, which is an important advantage over adjuvant chemotherapy 27,40.
Our findings highlighted the impact of LG versus OG in 2 groups of matched patients with GC. In agreement with the literature, our findings showed that LG was associated with a much lower intraoperative blood loss (P = 0.012), shorter length of hospital stay (P = 0.026), and a lower rate of postoperative complications (P = 0.16). On the other hand, the in-hospital mortality rate and types of postoperative complications were comparable in both groups. Regarding long-term outcomes, both groups were comparable in terms of 3-year survival (P = 0.23), mean survival time (P = 0.96), 3-year recurrence rate (P = 0.15), or metastasis (P = 0.26). Regarding the DFS, LG had higher DFS, but this was not significant (P = 0.21). These findings indicate that LG had more favorable intra- and postoperative outcomes in terms of safety and tolerability. However, the efficacy of LG compared with OG remains controversial.
The Korean Laparoendoscopic Gastrointestinal Surgery Study trial demonstrated that laparoscopic distal gastrectomy and open distal gastrectomy were almost similar in terms of 5-year survival (94.2% vs 93.3%; P = 0.64) and 5-year cancer-specific survival rates (97.1% vs 97.2%; P = 0.91). Both groups were comparable (P = 0.49 and P = 0.60, respectively) concerning total deaths and recurrence 37. The oncological safety of LG for GC was doubted, as the risk of locoregional recurrence was potentially increased owing to insufficient lymphadenectomy 16. An RCT conducted by Hu et al. showed similar compliance rates of D2 lymphadenectomy between LG and OG (99.4% vs 99.6%; P = 0.845), and comparable postoperative morbidity (15.2% vs 12.9%; P = 0.28) and mortality (0.4% vs 0%; P = 0.24) 41. In agreement with our findings, Yu et al. showed a similar 3-year DFS rate in LG (76.5%) and OG (77.8%) in patients with locally advanced GC. Furthermore, the 3-year OS rate, recurrence rate, and mortality rate were comparable in both groups (P = 0.28, P = 0.35, and P = 0.33, respectively) 21. In the retrospective analysis of Fujisaki et al., they reported comparable 5-year DFS (44.4% vs 53.3%; P = 0.382) and OS (46.9% vs 54.0%; P = 0.422) in LG and OG groups, respectively 42.
Anastomotic leakage and septic peritonitis are considered as major complications of gastric surgery. In our study, these 2 complications were the causes of death in 2 patients in the LG group. The anastomotic rate of leakage in the LG group reported by Hu et al. was 1.9% 41, which is within previously reported range 20,22,43,44. This differed from the research results of Rod et al., who show a high anastomotic leakage in the LG group (17%) especially in comparison to the OG group (10%). The overall postoperative complications (57% vs 48%; P = 0.128) and surgical complications (48% vs 27%; P = 0.005) were higher in the LG group compared with the OG group, but postoperative mortality was not influenced 45. Similarly, Haverkamp et al., reported a 37% complication rate in the LG group 46.
A recent meta-analysis of 15 studies showed that LG was associated with lower intraoperative blood loss (MD, − 76.95 ml; P < 0.001), postoperative hospital stay (MD, − 2.84 day; P < 0.001), and time to first oral intake (MD, − 0.88 day; P < 0.001). On the other hand, LG had a longer operative time and comparable postoperative mortality rate compared with OG 47. Another meta-analysis of 7 studies showed that LG was associated with lower blood loss (MD, − 127.47; P = 0.0009), reduced hospital stay (MD, − 5.26; P < 0.0001), shorter time to first oral intake (MD, − 0.94; P < 0.0001), time to first flatus (MD, − 1.04; P < 0.0001), time to first ambulation (MD, − 2.07; P < 0.0001), and longer operative time (MD, 15.73; P = 0.001). Regarding overall postoperative complications, surgical complications, medical complications, and pulmonary infections, LG showed favorable results compared with OG. However, in terms of the number of harvested lymph nodes, both groups were comparable (P = 0.11) 17.
Li et al. showed that after 4 cycles of neoadjuvant chemotherapy (SOX, CAPOX, or FOLFOX7 regimens), the findings of LG and OG were comparable in terms of distal and proximal margins, number of resected or metastatic lymph nodes, postoperative complications, operation time, blood loss, and length of hospital stay 27. After 3 years, they published an RCT showing that, among 95 patients with GC who were receiving neoadjuvant chemotherapy before surgery, the LG group had a substantially lower postoperative complication rate than the OG group (20% vs 46%; P = 0.007). Moreover, LG was associated with a lower postoperative pain score (visual analog scale) compared with OG (1.5 vs 3; P = 0.04) 48. Wu et al. compared 2 groups of GC patients. The first group received neoadjuvant chemotherapy before the surgery, and the second group was assigned to surgery directly. Total blood loss in a neoadjuvant group was substantially higher compared to that of the other group (320,79 vs 243,37 ml; P < 0,04). However, both groups were comparable regarding operative time (P = 0.65), lymph nodes harvested (P = 0.25), multiorgan resection (P = 0.054), and postoperative complications (P = 0.361) 49.
In locally advanced GC, pooling of 5 trials demonstrated that LG with D2 lymphadenectomy had equivalent overall short-term morbidity and mortality compared with OG 18. On the other hand, Best et al. found no significant difference in short- and long-term results between LG and OG 50. They disagreed with previous systematic reviews 15,51,52, which concluded that LG is better than OG and they believed that this conclusion was based on weak and heterogeneous studies.