Surgical Endoscopy

, Volume 27, Issue 7, pp 2598–2605

Comparison of short- and long-term outcomes of laparoscopic-assisted total gastrectomy and open total gastrectomy in gastric cancer patients

Authors

  • Moon-Soo Lee
    • Department of SurgerySeoul National University Bundang Hospital
    • Eulji University Hospital
  • Ju-Hee Lee
    • Department of SurgerySeoul National University Bundang Hospital
  • Do Joong Park
    • Department of SurgerySeoul National University College of Medicine
    • Department of SurgerySeoul National University Bundang Hospital
  • Hyuk-Joon Lee
    • Department of SurgerySeoul National University College of Medicine
    • Department of SurgerySeoul National University College of Medicine
    • Department of SurgerySeoul National University Bundang Hospital
  • Han-Kwang Yang
    • Department of SurgerySeoul National University College of Medicine
Article

DOI: 10.1007/s00464-013-2796-8

Cite this article as:
Lee, M., Lee, J., Park, D.J. et al. Surg Endosc (2013) 27: 2598. doi:10.1007/s00464-013-2796-8

Abstract

Background

Laparoscopy-assisted total gastrectomy (LATG) has been used more frequently despite the associated technical difficulty and concerns over oncological safety. This study was undertaken to compare the short- and long-term surgical outcomes following either LATG or open total gastrectomy (OTG) for gastric cancer.

Methods

A total of 120 LATG and 228 OTG were retrospectively matched with respect to sex, age (±5 years), and pathological tumor-node-metastasis stage for comparison of the clinical outcomes.

Results

The total complication rate among 120 LATG and 228 OTG was 18.3 % (22/120) and 16.2 % (37/228), respectively. The most common complication after LATG was anastomotic-related complication (6.7 %); five anastomotic leakages (4.2 %) and three anastomotic strictures were reported (2.5 %). That after OTG was wound complication (3.5 %), including seroma or infection. Matched patients analysis: Time to first gas passing and time to the resumption of a soft diet were significantly shorter in the LATG group than in the OTG group. The postoperative hospital stay of LATG was shorter in the LATG group (9.3 ± 4.2 days) than in the OTG group (11.7 ± 7.3 days; p = 0.057). Among matched patients, there was no significant difference between complication rate (24 vs. 32 %; p = 0.504) or leakage rate (6 vs. 4 %). During median follow-up of 50 (range, 10–92) months, there was no significant difference in the disease-free survival rate between the matched groups, respectively (94.5 vs. 87.1 %: p = 0.148). As for patients with TNM stage I gastric cancer, the disease-free survival rate (100 vs. 90.9 %; p = 0.5) and the cumulative survival rate (91.5 vs. 95.2 %; p = 0.618) did not differ significantly between the LATG and OTG groups.

Conclusions

LATG for gastric cancer has the advantage over an OTG in terms of better short-term outcomes and similar long-term outcome. LATG is an acceptable alternative to OTG for the treatment of gastric cancer.

Keywords

Total gastrectomyLaparoscopyGastric cancer

The use of laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer has rapidly increased since the first report by Kitano et al. [1]. LADG for early gastric cancer has already been accepted in terms of postoperative benefits, such as reduced pain and shorter hospital stays, morbidity, and mortality, over conventional open surgery [2]. Recently, the indication for laparoscopic surgery has been extended from early gastric cancer to advanced gastric cancer [3]. However, the use of laparoscopy-assisted total gastrectomy (LATG) is not yet widespread because of the technical difficulty involved in completing the procedures, concerns over oncological safety, and the uncertainty of the associated indications [4]. Few reports have compared the outcomes of LATG versus open total gastrectomy (OTG) [5]. Therefore, this study was designed to evaluate the short-term and long-term outcomes of LATG as well as the safety and feasibility of the technique, using a matched case–control study.

Materials and methods

This study used a prospectively collected gastric cancer database of patients who underwent LATG and OTG at the Seoul National University Bundang Hospital from June 2003 to May 2010. Because LATG was first performed in our hospital as long ago as June 2003, data were available for 120 consecutive LATG patients and 228 OTG patients. The indication for LATG initially included depth of tumor invasion limited to the mucosa or submucosa and absence of lymph node metastases located in upper and middle gastric portion in preoperative examinations. However, the indication for LATG was gradually extended to advanced gastric cancer. The patients in whom the LATG was converted to an OTG also were excluded from the present study. The clinical variables of all LATG and OTG patients were analyzed by retrospective database review. We then extracted patients who were matched with respect to sex, age (±5 years), and pathological tumor-node-metastasis (TNM) stage. Patients who had histological or gross evidence of residual tumor during surgery were excluded. Finally, 50 patients who underwent an LATG and 50 who underwent an OTG were matched. The matched cases were analyzed with respect to clinical parameters in patients. The perioperative variables included operative time, blood loss, and hospital stay, as well as postoperative outcomes, such as morbidity and mortality. All patients were treated by a single surgeon who had experience with more than 1,000 cases of laparoscopic gastrectomy. Major postoperative complications were defined as surgical complications, including anastomotic leakage, pancreatic fistula, and abdominal abscess. Other postoperative complications were defined as minor events resulting in a delay in discharge from the hospital or readmission to the hospital within 30 days of discharge. All data are expressed as mean ± standard deviation. Statistical analyses, including the Chi square test and Student’s t test, were conducted using SPSS® (version 12.0 for Windows; SPSS, Inc., Chicago, IL). Disease-free survival and cumulative survival rate were estimated using Kaplan–Meier curves. The stratified log-rank test was used to evaluate the differences between the LATG and OTG groups. p values <0.05 were considered to indicate statistical significance.

Operative technique of D2 total gastrectomy

OTG was performed in the usual manner through an approximately 20-cm long upper-midline incision. LATG was performed using five ports (two 5-mm bilateral costal arch ports: one 12-mm and one 5-mm port, which were placed laterally to the rectus sheath, and one 12-mm camera port; Fig. 1). An initial 12-mm trocar was carefully inserted through the supraumbilical incision for the laparoscopic scope using the open technique. Full examination of the abdominal cavity was performed to search for distant metastasis and direct invasion of adjacent organs. The CO2 pneumoperitoneum was maintained at 12–14 mmHg during the operation. The dissection of lymph nodes and vessel division necessary for LATG was performed similarly to the LADG method using the harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH) except for the pericardial area and distal pancreatic portion including the splenic hilum. The trocar incision in the left lower area was extended 5–6 cm transversely at the umbilical level; Roux-en-Y esophagojejunostomy and jejunojejunostomy reconstruction were performed through this incision. The dissected lower esophagus was divided using Endo-PSI through the left medial extended port incision. The anvil head was inserted into the opened distal esophagus and tied. The jejunum was brought through the anterocolic route after dividing the jejunum, which is located 20 cm from the ligament of Treitz, and the shaft of the circular stapler was introduced into the distal segment of the jejunum followed by an end-to-side esophagojejunostomy. The access opening on the jejunal stump then was closed with a laparoscopic linear stapler. The side-to-side esophagojejunostomy was performed using a linear stapler (ETS; Ethicon Endo-Surgery) through two each access opening of jejunal loop and the divided esophagus and the opening was closed using intracorporeal continuous suture. The side-to-side jejunojejunal anastomosis was performed using a 45-mm endoscopic linear stapler (ETS) through the minilaparotomy; the length between the esophagojejunostomy and the jejunojejunal anastomosis was approximately 40 cm. An end-to-side esophagojejunostomy was performed during all OTG using a circular stapler (CDH, 25 mm; Ethicon Endo-Surgery) and esophagojejunostomy for LATG was achieved using a linear (side-to-side anastomosis) or a curved circular stapler. In this study, 99 end-to-side and 21 side-to-side anastomoses were performed for esophagojejunostomy in LATG.
https://static-content.springer.com/image/art%3A10.1007%2Fs00464-013-2796-8/MediaObjects/464_2013_2796_Fig1_HTML.gif
Fig. 1

Sites of trocar and minilaparotomy

In one case of total gastrectomy with splenectomy or distal pancreatectomy for curative resection, we first started dissecting the gastrocolic ligament toward the splenic lower pole. The pancreatic lower margin was incised, which allowed for adequate mobilization of the pancreatic tail and spleen. After performing lymph node dissection along the splenic vessel, the splenic vessel was divided at the distal portion of the dorsal pancreatic artery. In case of distal pancreatectomy, we used Endo GIA for the division of distal pancreas.

Results

Clinical characteristics of unmatched total LATG and OTG patients

This study included 76 males (63 %) in unmatched total LATG group. The median age of 120 LATG patients was 57.7 ± 11.6 years (range, 30–82). The average body mass index (BMI) was 23.6 ± 3.4 (range, 14.4–31.8). The demographic characteristics of unmatched total OTG patients are described in Table 1. The pathologic characteristics of total LATG and OTG patients are outlined in Table 2. There is significant difference between two groups in term of tumor size, tumor location, and stage distribution (p < 0.001). In four patients (3.2 %), the approach was converted from LATG to OTG. One reason for conversion to OTG was the inability to establish a secure esophagojejunostomy during the course of LATG; more esophageal resection was needed due to the positive resection margin and poor blood supply after esophagojejunostomy. In another patient, dense adhesion was found between the stomach and pancreas; this was difficult to separate laparoscopically. In another case, conversion was enforced due to intraperitoneal bleeding during dissection of the splenic hilum. Those patients were excluded in this study.
Table 1

Demographic characteristics of the unmatched patients

Variable

Value (%)

p value

Operative method

LATG (n = 120)

OTG (n = 228)

Age (year)

57.7 ± 11.6

58.2 ± 12.1

0.702

Male:female ratio

76:44

156:72

0.342

BMI (kg/m2)

23.6 ± 3.4

22.6 ± 3.1

0.011

ASA score

  

0.054

 I

74 (61.7)

144 (63.2)

 

 II

39 (32.5)

81 (35.5)

 

 III

7 (5.8)

3 (1.3)

 

LATG laparoscopy-assisted total gastrectomy, OTG open total gastrectomy, BMI body mass index, ASA American Society of Anesthesiology

Table 2

Pathologic characteristics of the tumors in unmatched total LATG and OTG patients

Variable

Value (%)

p value

LATG (n = 120)

OTG (n = 228)

 

Tumor size (cm; mean SD)

4.9 ± 3.5

7.4 ± 4.1

<0.01

Tumor location

  

<0.001

 Upper 1/3

86 (71.7)

135 (59.2)

 

 Middle 1/3

28 (23.3)

43 (18.9)

 

 Whole involvement

6 (5)

50 (21.9)

 

Depth of tumor invasion

  

<0.001

 T1

62 (51.7)

33 (14.5)

 

 T2

36 (30)

102 (44.7)

 

 T3

22 (18.3)

86 (37.7)

 

 T4

0 (0)

7 (3.1)

 

Lymph node metastasis

  

<0.001

 N0

79 (65.8)

64 (28.1)

 

 N1

24 (20)

67 (29.4)

 

 N2

11 (9.2)

50 (21.9)

 

 N3

6 (5)

47 (20.6)

 

Distant metastasis

  

0.001

 M0

119 (99.2)

205 (89.9)

 

 M1

1 (0.8)

23 (10.1)

 

TNM stage

  

<0.001

 Ia

60 (50)

23 (10.1)

 

 Ib

18 (15)

41 (18)

 

 II

17 (14.2)

48 (21.1)

 

 IIIa

13 (10.8)

41 (18)

 

 IIIb

6 (5)

23 (10.1)

 

 IV

6 (5)

52 (22.8)

 

LATG laparoscopy-assisted total gastrectomy, OTG open total gastrectomy

Postoperative clinical course of the unmatched patients

The clinical outcomes after unmatched LATG and OTG are listed in Table 3. The median operation time was significantly longer in the LATG group (250 ± 50 min) than in the OTG group (194 ± 53 min, p < 0.001). Time to first flatus was significantly shorter in the LATG group (3.9 ± 1.1 days) than in the OTG group (4.6 ± 1.4 days, p < 0.001). Time to tolerance of a soft diet also was significantly shorter in the LATG group (5.0 ± 2.3 days, p = 0.026) than in the OTG group (5.6 ± 2.5 days). The postoperative hospital stay of LATG patients was shorter (9.6 ± 6.3 days) than that of the OTG group (11.7 ± 7.4 days, p = 0.008).
Table 3

Operative outcomes of unmatched LATG and OTG patients

Variable

Value (range)

p value

Operative method

LATG (n = 120)

OTG (n = 228)

Operating time (min; mean SD)

250 ± 50 (range, 155–395)

194 ± 53 (range, 90–360)

<0.001

No. of retrieved lymph nodes (mean ± SD)

52.3 ± 19.4 (19–128)

52 ± 20.9 (3–127)

0.886

Time to first flatus

3.9 ± 1.1 (2–7)

4.6 ± 1.4 (2–11)

<0.001

Time to first intake of a soft diet

5.0 ± 2.3 (3–22)

5.6 ± 2.5 (3–30)

0.026

Hospital stay (days)

9.6 ± 6.3 (5–43)

11.7 ± 7.4 (4–57)

0.008

Estimated blood loss (ml)

215 ± 188 (10–950)

194 ± 165 (30–1,500)

0.301

Variable

Value (%)

  

Method of anastomosis

   

 End-to-side:side-to-side

99:21

120:0

<0.001

Combined resection

  

0.001

 No

90 (75)

203 (89)

 

 Yes

30 (25)

25 (11)

 

Postoperative morbidity

   

 Present/absent

22/98

37/191

0.653

 Major

   

  Anastomotic leakage

5 (4.2)

5 (2.2)

 

  Intra-abdominal abscess

5 (4.2)

7 (3.1)

 

  Pancreatitis

0 (0)

2 (0.9)

 

 Minor

   

  Wound complication (seroma, infection)

2 (1.7)

8 (3.5)

 

  Intraluminal and intra-abdominal bleeding

2 (1.7)

3 (1.3)

 

  Anastomotic stricture

3 (2.5)

4 (1.8)

 

  Ileus

4 (3.3)

2 (0.9)

 

  Hepatitis

1 (0.8)

1 (0.4)

 

  Pneumonia

0 (0)

2 (0.9)

 

  Other (MI)

0 (0)

2 (0.9)

 

Total complication rate

22/120 (18.3)

37/228 (16.2)

 

Postoperative mortality

0 (0)

0 (0)

 

LATG laparoscopy-assisted total gastrectomy, OTG open total gastrectomy

Postoperative complications of the unmatched patients

There is no significant difference of complication between unmatched total LATG and OTG patients (p = 0.653). The most common complication after LATG was an anastomotic-related complication (6.7 %); we observed five anastomotic leakages (4.2 %) and three anastomotic strictures (2.5 %). Of the five patients with esophagojejunostomy leakage, the condition was resolved in four patients using percutaneous drainage and conservative therapy. However, reoperation was needed for one patient with anastomosis disruption. The median time from LATG to balloon dilatation for three anastomotic strictures was 5.6 ± 3.2 (range, 2–8 months). However, there is no significant difference for complications, including esophagojejunostomy leakage in LATG according to anastomotic method, end-to-side (17.1 %) and side-to-side type (23.8 %; p = 0.536). Three of four cases of postoperative ileus developed at the jejunojejunostomy site. These two cases were addressed using balloon dilation and stenting. However, a jejunojejunostomy revision procedure was required for the other patient. The most common complication after OTG was wound complication (3.5 %), including seroma or infection. The total complication rate of LATG and OTG was 18.3 % (22/120) and 16.2 % (37/228), and there were no incidences of postoperative mortality.

Matched case–control analysis

Clinical characteristics of the matched patients

The characteristics of the matched subjects are summarized in Table 4. Age, sex, BMI, physical status according to the American Society of Anesthesiology (ASA) guidelines, and TNM were similar between the OTG and LATG groups.
Table 4

Demographic characteristics of the matched patients

 

LATG (n = 50)

OTG (n = 50)

p value

Age (year)

50.6 ± 22.1

51 ± 22.6

0.933

Male:female

32:18

32:18

1

BMI (kg/m2)

23.2 ± 3.7

23 ± 3.4

0.74

ASA score (1/2/3)

34/11/5

31/16/3

0.457

p TNM stage

  

1

 Ia

15

15

 

 Ib

9

9

 

 II

13

13

 

 IIIa

7

7

 

 IIIb

2

2

 

 IV

4

4

 

LATG laparoscopy-assisted total gastrectomy, OTG open total gastrectomy, BMI body mass index, ASA American Society of Anesthesiology

Operative findings among the matched patients

There was no difference between the two groups in terms of combined resection, the number of dissected lymph nodes, or estimated blood loss (Table 5). However, side-to-side anastomosis was performed more frequently for LATG than for OTG patients (p < 0.001). The median operation time was significantly longer in the LATG group (258 ± 54 min) than in the OTG group (198 ± 57 min, p < 0.001).
Table 5

Operative outcomes of the matched patients

 

LATG (n = 50)

OTG (n = 50)

p value

Method of anastomosis

  

<0.001

 End-to-side:side-to-side

38:12

50:0

 

Combined resection

  

0.192

 Presence:absence

12:38

6:44

 

Operation time (min)

258 ± 54

198 ± 57

<0.001

Estimated blood loss (ml)

167.3 ± 135.2

178.4 ± 107

0.653

No. of dissected lymph nodes

48.4 ± 18.4

54.3 ± 20.5

0.134

Time to first flatus (days)

4 ± 1.2

4.5 ± 1.5

0.047

Time to soft diet (days)

5 ± 1.7

6.1 ± 2.5

0.017

Hospital stay (days)

9.3 ± 4.2

11.7 ± 7.3

0.057

LATG laparoscopy-assisted total gastrectomy, OTG open total gastrectomy

Postoperative clinical course of the matched patients

Time to first flatus was significantly shorter in the LATG group (4.0 ± 1.2 days) than in the OTG group (4.5 ± 1.5 days, p = 0.047). Time to tolerance of a soft diet also was significantly shorter in the LATG group (5.0 ± 1.7 days, p = 0.017) than in the OTG group (6.1 ± 2.5 days). The postoperative hospital stay of LATG patients showed shorter trend (9.3 ± 4.2 days) than that of the OTG group (11.7 ± 7.3 days, p = 0.057).

Postoperative complications of the matched patients

The postoperative complications are outlined in Table 6. There was at least one complication in 12 of 50 (24 %) of LATG patients versus 16 of 50 (32 %) of the OTG patients. There is no significant difference with respect to the complication rate observed in matched patients (p = 0.504). The most common postoperative morbidity associated with OTG was wound complications (seroma in 2 cases, infection in 3 cases). In the LATG group, the most common complication was esophagojejunostomy-related problems, including leakage and stricture. There were three anastomotic leakages at the esophagojejunostomy site in LATG patients (3/50, 6 %); one patient required operative correction, and two patients were controlled with conservative treatment. Three anastomotic strictures were detected during the follow-up period after LATG (3/50; 6 %). There was no postoperative mortality among the matched patients.
Table 6

Postoperative complications in the matched cases

 

LATG (n = 50)

OTG (n = 50)

p value

Present/absent

12/38

16/34

0.504

 Major

  Anastomotic leakage

3 (6 %)

2 (4 %)

 

  Abdominal abscess

3 (6 %)

1 (2 %)

 

  Pancreatitis

0 (0 %)

1 (2 %)

 

 Minor

   

  Bleeding

0 (0 %)

2 (4 %)

 

  Anastomotic stricture

3 (6 %)

2 (4 %)

 

  Wound complication(seroma, infection)

1 (2 %)

5 (10 %)

 

  Hepatitis

1 (2 %)

1 (2 %)

 

  Ileus

1 (2 %)

1 (2 %)

 

  Other (MI)

0 (0 %)

1 (2 %)

 

 Complication rate

24 %

32 %

 

 Mortality

0 (0 %)

0 (0 %)

 

LATG laparoscopy-assisted total gastrectomy, OTG open total gastrectomy

Survival data of matched patients

Among matched 100 patients, survival data were available for 97 patients, and the median follow-up period was 38.2 ± 22 (range, 10–89) months in the LATG group and 60.8 ± 19.8 (range, 15–92) months in the OTG group. During median follow-up of 50 months (range, 10–92), there was no significant difference in the disease-specific survival rate between the matched LATG and OTG groups, respectively (94.5 vs. 87.1 %: p = 0.148; Fig. 2). As for patients with TNM stage I gastric cancer, the disease-free survival rate (100 vs. 90.9 %; p = 0.5) and the cumulative survival rate (91.5 vs. 95.2 %; p = 0.618; Fig. 3) did not differ significantly between the LATG and OTG groups.
https://static-content.springer.com/image/art%3A10.1007%2Fs00464-013-2796-8/MediaObjects/464_2013_2796_Fig2_HTML.gif
Fig. 2

Disease-free survival curve of patients undergoing laparoscopy-assisted (LATG) and open total gastrectomy (OTG) during a 92-month interval. The two groups did not differ significantly (p = 0.148)

https://static-content.springer.com/image/art%3A10.1007%2Fs00464-013-2796-8/MediaObjects/464_2013_2796_Fig3_HTML.gif
Fig. 3

Cumulative survival curve of patients undergoing laparoscopy-assisted (LATG) and open total gastrectomy (OTG) for stage I gastric cancer. The two groups did not differ significantly (91.5 vs. 95.2 %; p = 0.618)

One patient died of hepatic failure, and one patient in the LATG group with stage I was alive with peritoneal recurrence 2 years after the operation. No port-site recurrence occurred in the LATG group.

One patient in the OTG group with stage I died of idiopathic pulmonary fibrosis; the other died of accident. There is no recurrence after OTG.

Discussion

Laparoscopic surgery has been performed already as the standard treatment for several benign diseases and some malignant diseases, such as colon cancer [6]. LADG for early gastric cancer has gradually been accepted due to the short-term benefits, such as less postoperative pain, faster recovery, and shorter hospital stays, as well as its oncological aspects compared with conventional open gastrectomy. Additionally, some authors have reported that the use of LADG for advanced gastric cancer is feasible and safe [79]. The major indications and technical aspects for LATG are basically similar to those for LADG [10]. As laparoscopic technique has improved, the number of LATG cases has increased annually. Lee et al. [11] reported that LATG is a technically feasible procedure compared with LADG. However, many surgeons hesitate to undertake LATG, because it is more difficult to perform than LADG due to the additional requirement for dissection of lymph nodes at the splenic hilum or along the short gastric artery and, especially, the need for esophagojejunostomy. Therefore, most surgeons attempt LATG only after many years of experience with OTG and LADG for early gastric cancer. Similar to the situation at other institutions, most cases of LATG at our institute were early gastric cancer; most OTG cases were advanced gastric cancer. Therefore, we used the retrospective case-matched analysis to overcome this significant discordance of TNM pathologic stage observed between the groups. Because few reports have compared a large number of LATG and OTG cases, this comparison of postoperative outcomes in both groups using the case–control method is considered valid, despite the inherent limitations of a small study size.

Sakuramoto et al. [12] reported that there is no significant difference between OTG and LATG in terms of technical safety. Comparison of the two techniques showed that LATG is an excellent treatment option for upper or middle gastric cancer. Tanimura et al. [13] also suggested that LATG might be a safe, curative procedure for upper gastric cancer in terms of operating time, blood loss during the operation, lymph node retrieval, and morbidity. In the present study, there was no significant difference between the groups in terms of estimated blood loss or number of resected lymph nodes. However, the operation time was significantly longer for an LATG than OTG procedure, because the LADG procedure requires more time than ODG [14]. These findings are consistent with previous reports on LATG [12]. Kitano et al. [15] reported a multicenter study of the oncologic outcomes of LAG for 1,294 patients with gastric cancer in Japan, among whom 55 patients underwent LATG. The authors reported a mean operating time of 271 min. Usui et al. [5] also concluded that LATG has the advantage compared with OTG of a shorter recovery time, in terms of shorter time to first flatus, time to initiate oral intake, and postoperative hospital stay. These results are similar to our report.

The overall incidence of complications of LATG and OTG (32 vs. 24 %) is similar to that obtained in previous studies. Lang et al. [16] reported that the postoperative morbidity of 1,114 patients with OTG was 30.4 %, whereas other studies [17, 18] have reported postoperative morbidity rates of 13–14 % for OTG. Mochiki et al. [4] reported the rate of postoperative morbidity of LATG as 25 %. The most common complication of LATG was esophagojejunostomy leakage in matched cases (6 %) and stricture in unmatched cases (6 %). Lee et al. [11] reported the most common complication of LATG as esophagojejunal stricture (6/67; 9 %), whereas Jeong et al. [19] reported that there was no anastomotic stricture after LATG in their multicenter study. In our study, all cases with stricture were resolved by using endoscopic balloon dilation during the follow-up period. We tried two methods for searching more secure method of esophagojejunostomy during the study period. The end-to-side esophagojejunostomy is generally common anastomotic method. However, the anvil insertion through the divided esophagus is difficult procedure during LATG, especially for small-sized esophagus. Therefore, we mainly selected the side-to-side anastomotic method for a narrow esophagus. Bracale et al. [20] also suggested that side-to-side esophagojejunostomy is a safe and feasible technique, especially in the presence of a narrow esophagus. In our study, there also is no significant difference for complications, including esophagojejunostomy leakage between end-to-side and side-to-side LATG anastomotic method. Reoperations were needed for one patient with esophagojejunal leakage in the OTG group and one patient with stricture of the jejunojejunal anastomosis in the LATG group. The other complications were controlled using conservative management. In our study, there is some tendency that major complications, such as anastomosis-related leakage or stricture, was more prevalent in LATG but that usually occurred in the early starting period. So, we believe that it is a matter of learning curve.

The long-term oncologic results of LATG have not yet been determined. Mochiki et al. [4] suggested LATG can be a curative for EGC in terms of oncological safety through the comparison of 5-year cumulative survival between LATG and OTG. In this study, we also confirmed similar long-term oncological outcomes of LATG compared with those of OTG, especially in EGC. Hamabe et al. [3] reported that laparoscopic-assisted gastrectomy, including the 21 LATG and 35 OTG cases is acceptable in terms of long-term oncological results for AGC treatment. However, in our study, there seems to be some difficulty comparing the long-term survival rates between LATG and OTG for AGC patients due to the small number of the matched group.

Conclusions

LATG for gastric cancer has the advantage over an OTG in terms of better short-term outcomes and similar long-term outcome. LATG is an acceptable alternative to OTG for the treatment of gastric cancer. A prospective, multicenter, randomized trial comparing LATG and OTG must be confirmed as a standard procedure for upper and middle gastric cancer.

Disclosures

Drs. M.-S. Lee, J.-H. Lee, D. J. Park, H.-J. Lee, H.-H. Kim, and H.-K. Yang have no conflicts of interest or financial ties to disclose.

Copyright information

© Springer Science+Business Media New York 2013