Long-Term Outcomes in Laparoscopic D2 Gastrectomy for Gastric Cancer: a Large Comprehensive Study Proposing Novel Hypotheses
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The long-term outcomes of laparoscopic gastrectomy (LG) versus open gastrectomy (OG) for gastric cancer (GC) remain obscure, especially for advanced cancer and disease affecting the upper stomach and in older patients. This study aimed to comprehensively assess the long-term efficacy of LG for GC using a large prospective database.
Totally, 1877 consecutive patients (1186 receiving LG and 691 OG) operated in 2004–2016 were analyzed, with a median follow-up of 63 months. Association of LG versus OG with disease-specific survival (DSS) and disease-free survival (DFS) overall and in various subgroups were investigated using multivariable Cox regression. Propensity score matching (PSM) was performed for sensitivity analysis.
Before PSM, overall, there was no significant association of LG versus OG with survival after multivariable adjustment; however, in subgroup analyses, LG was associated with superior DSS in patients aged ≥ 70 years and those with upper GC. No significant associations regarding DFS were observed overall or in stratifications. PSM analyses revealed that LG was associated with better DSS also in patients aged ≥ 70 years (hazard ratio (HR) = 0.33, 95% confidence interval (CI) = 0.15–0.72) and in those with upper GC (HR = 0.51, 95% CI = 0.29–0.91), and with better DFS in those with upper GC (HR = 0.60, 95% CI = 0.37–0.99). Multivariable analysis showed that age, hepatitis B, performance status, tumor histology, stage, and vascular invasion were significantly associated with post-LG survival. LG-specific nomograms were then constructed with concordance indexes of 0.814 (DSS) and 0.809 (DFS) and excellent calibration.
In this large institutional analysis, while LG for GC was associated with DSS and DFS similar to those for OG overall, non-inferior LG-associated survival especially DSS was observed in some subgroups rarely investigated in prospective or randomized settings. There could still be biases even after PSM due to confounders not accounted for in this observational study. However, these findings offer novel hypotheses for further validation.
KeywordsGastric cancer Laparoscopic gastrectomy Open gastrectomy Long-term outcomes Propensity score matching Nomogram
We are grateful to the documenters in Nanfang Hospital for data collection, and to members of the Chinese Laparoscopic Gastrointestinal Surgery Study Group, the Chinese Gastric Cancer Association, the Chinese Society of Laparo-Endoscopic Surgery, and the Chinese Society of Gastrointestinal Surgery for support.
Lei Huang had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Conception and design: Lei Huang, Tuan-Jie Li, Guo-Xin Li
Collection and assembly of data: All authors
Analysis and interpretation of data: Lei Huang, Tuan-Jie Li, Guo-Xin Li
Drafting of manuscript: Lei Huang
Critical revision of manuscript: Tuan-Jie Li, Guo-Xin Li
All authors reviewed and approved the manuscript for publication.
This work was supported by grants from State’s Key Project of Research and Development Plan (2017YFC0108300 and 2017YFC0108301), National Natural Science Foundation of China (81672446), Guangdong Provincial Science and Technology Key Project (2014A020215014), Research Fund of Public Welfare in the Health Industry, the National Health and Family Planning Commission of China (201402015), the Southern Medical University Clinical Research Start-Up Project (LC2016ZD003), Guangzhou Science and Technology Project (201400000004-5), the Key Clinical Specialty Discipline Construction Program (170), and President Funding of Nanfang Hospital (2016B010). The funders had no role in study design, in the collection, analysis, or interpretation of data, or in the writing of the report.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no competing interests.
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