Laparoscopic Versus Open D2 Gastrectomy for the Treatment of Gastric Cancer: a Singapore Institution’s Experience over 7 Years

Abstract

Introduction: Gastric cancer is a leading cause of cancer related mortality in Singapore and open surgical resection with en-bloc lymphadenectomy is currently the standard of care. While the benefits of laparoscopic surgery for other cancers such as colorectal cancer have been widely accepted. It has seen slower acceptance for gastric cancer due to the steep learning curve, concerns regarding long-term oncological outcome and adequacy of harvested lymph nodes. Our study aims to compare our institution's short term outcomes of laparoscopic gastrectomies (LG) for cancer to open gastrectomy (OG). Materials & Methods: A retrospective review of patients who underwent gastrectomies for stomach cancer from July 2008 to December 2015 was done. All patients underwent either partial or total gastrectomy with the intention of D2 lymphadenectomy as per the Japanese gastric cancer guidelines by one of four upper gastrointestinal consultant surgeons. The decision to undertake an open or laparoscopic approach was made after discussion between the surgeon and the patient. Patients who had metastatic gastric cancer or underwent gastrectomy for palliation were excluded. All patients were followed up for at least five years postoperatively. Patient demographics, tumour characteristics, operative details, and post-operative outcomes were analysed using SPSS version 21. Results: 164 patients underwent gastrectomies between 2008 and 2015. 58 were OG and 106 were LG. There were 9 conversions from laparoscopic to open surgery. More stage III cancers underwent OG (n=43) while stage I and II cancers underwent LG (n=75). The laparoscopic group had longer operative time (268 min vs 223 min, p<0.001) with a non-significant trend towards less blood loss (287ml vs 330ml) and shorter length of stay (10 days vs 13 days). There was no significant difference between number of lymph nodes harvested (35 vs 32), re-operation rate, 30-day morbidity and mortality. There was a significantly higher recurrence rate (43% vs 15%, P<0.001) with OG, however this did not affect overall survival between OG and LG (25 months vs 30 months, P=0.173). Conclusion: The number of lymph nodes harvested and 30-day morbidity of LG is equivalent to the current gold standard of OG. The higher recurrence rate of open surgery is likely due to more OG being performed for higher stage tumours. Our study shows that LG for gastric cancer is safe and feasible in experienced hands.