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Importance: It is largely unclear whether robotic distal gastrectomy (RDG) is cost-effective for locally advanced gastric cancer (LAGC). Objective: To evaluate the cost-effectiveness of RDG, laparoscopic distal gastrectomy (LDG), and open distal gastrectomy (ODG) for patients with LAGC. Design, setting, and participants: Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. A decision-analytic model was constructed to evaluate the cost-effectiveness of RDG, LDG, and ODG. Exposures: RDG, LDG, and ODG. Main outcomes and measures: Incremental cost-effectiveness ratio (ICER) and quality-adjusted life year (QALY). Results: This pooled analysis of two randomized controlled trials included 449 patients: 117, 254, and 78 patients in the RDG, LDG, and ODG groups, respectively. After IPTW, RDG demonstrated its priority in terms of less blood loss, postoperative length, and complication rate (all P< 0.05). RDG also showed higher QOL with more cost, representing an ICER of $85,739.73 per QALY and $42,189.53 per QALY compared to LDG and ODG, respectively. In probabilistic sensitivity analysis, RDG achieved the best cost-effectiveness for patients with LAGC only when the willingness-to-pay threshold was > $85,739.73 per QALY, which significantly exceeded 3 times Chinese per capita GDP. Furthermore, one of the most important factors was the indirect costs of robotic surgery in terms of the cost-effectiveness of RDG compared to that of LDG or ODG. Conclusions and relevance: Although improved short-term outcomes and QOL were seen in patients underwent RDG, the economic burden should be considered in the clinical decision-making regarding robotic surgery use for patients with LAGC. Our findings may vary in different health care settings and affordability.

Background: It remains inconclusive whether laparoscopic gastrectomy (LG) has better long-term outcomes when compared with open gastrectomy (OG) for elderly gastric cancer (EGC). We attempted to explore the influence of the immune prognostic index (IPI) on the prognosis of EGCs treated by LG or OG to identify a population among EGC who may benefit from LG. Methods: We included 1539 EGCs treated with radical gastrectomy from January 2007 to December 2016. Propensity score matching was applied at a ratio of 1:1 to compare the LG and OG groups. The IPI based on dNLR ≥ cut-off value (dNLR) and sLDH ≥ cut-off value (sLDH) was developed, characterizing two groups (IPI = 0, good, 0 factors; IPI = 1, poor, 1 or 2 factors). Results: Of the 528 EGCs (LG: 264 and OG: 264), 271 were in the IPI = 0 group, and 257 were in the IPI = 1 group. In the entire cohort, the IPI = 0 group was associated with good 5-year overall survival (OS) (p= 0.001) and progression-free survival (PFS) (p= 0.003) compared to the IPI = 1 group; no significant differences in 5-year OS and PFS between the LG and OG groups were observed. In the IPI = 1 cohort, there was no significant difference in OS or PFS between the LG and OG groups across all tumor stages. However, in the IPI = 0 cohort, LG was associated with longer OS (p= 0.015) and PFS (p= 0.018) than OG in stage II EGC, but not in stage I or III EGC. Multivariate analysis showed that IPI = 0 was an independent protective factor for stage II EGC receiving LG, but not for those receiving OG. Conclusion: The IPI is related to the long-term prognosis of EGC. Compared with OG, LG may improve the 5-year survival rate of stage II EGC with a good IPI score. This hypothesis needs to be further confirmed by prospective studies.

Background: The oncologic efficacy of laparoscopic versus open surgery for advanced distal gastric cancer (ADGC) beyond 3 years after surgery remain obscure. Methods: A total of 1256 patients with ADGC at two teaching institutions in China from April 2007 to December 2014 were enrolled. The general data of the two groups were identified to enable rigorous estimation of propensity scores. Restricted mean survival time (RMST) and Landmark analysis was used to compare survival. Results: After matching 461 patients each in the open distal gastrectomy (ODG) and laparoscopic distal gastrectomy (LDG) groups, they were included into analysis. The 3- and 5-year overall survival (OS) and disease-free survival were comparable in two groups. RMST-stratified analysis showed that the 3-year RMST of ODG group was similar to that of LDG group in patients with cT4a (− 1.38 years, p= 0.163) or with cT4a and tumor size > 5 cm, whereas the 5-year RMST had significant differences between groups in cT4a patients(− 8.36 years, P= 0.005) or cT4a and tumor size > 5 cm patients(4.67 years, P= 0.042). In patients with cT4a and tumors > 5 cm, the number of peritoneal recurrences was significantly fewer in the ODG group than in the LDG group (4 vs. 17, P= 0.033), and the peritoneal recurrence time and multiple-site recurrence time were both later in the ODG group. Conclusion: By reducing recurrence, ODG achieves a better survival for GC patients with serous infiltration and tumors larger than 5 cm beyond 3 years after surgery. The present findings can serve as a reference for surgical options and the setting of follow-up time point for clinical studies.

Background: Numerous studies have shown that the short-term efficacy of three-dimensional (3D) laparoscopic radical gastrectomy (LG) is comparable to that of two-dimensional (2D)-LG. Whether 3D-LG affects the recurrence patterns of gastric cancer (GC) patients has not been investigated. Methods: From January 2015 to April 2016, a total of 419 patients were recruited for a phase III clinical trial (NCT02327481), which compared the short-term outcomes between the 2D and 3D groups. The long-term efficacy including recurrence patterns was compared between the 2D and 3D groups in this retrospective study. Multivariate analyses were performed to determine whether 3D-LG affects the recurrence patterns. Results: Ultimately, 401 patients were analyzed (197 in the 2D-LG group and 204 in the 3D-LG group), and no differences were observed in the clinicopathological data between the two groups. There were no significant differences between the two groups in the recurrence types, first recurrence time or recurrence-free survival (RFS) (all p?>?0.05). According to the 7th American Joint Committee on Cancer tumor-node-metastasis (TNM) staging system, both groups were stratified into pathological stages I, II, and III. The stratified analysis showed no significant differences in RFS or overall survival (OS) among patients in each subgroup (all p?>?0.05). The multivariate analysis of RFS showed that tumor diameter, pTNM stage, lymphovascular invasion, and adjuvant chemotherapy were independent factors (all p?<?0.05). The multivariate analysis of post-recurrence survival (PRS) showed that adjuvant chemotherapy was an independent protective factor (p?=?0.043). Conclusions: 3D-LG for GC did not differ significantly from 2D-LG in the effects on 3-year recurrence patterns, RFS and OS, which provides more tumor-related evidence for 3D technology. And due to the technological similarity, it may have certain reference value for robotic-assisted gastrectomy. Further multicenter, large-scale clinical trials are warranted.

Background: Well-designed retrospective studies (RSs) and small-sample prospective studies (PSs) evaluating the efficacy of interventions have received much attention. This study was designed to evaluate the differences between well-designed RSs and small-sample randomized controlled trials based on the efficacy of laparoscopic distal gastrectomy (LDG) and open distal gastrectomy (ODG) for advanced gastric cancer (GC). Methods: The clinicopathological data of 1360 patients with GC who underwent DG were analysed. After propensity score matching (1:1), 380 cases (ODG = 190, LDG = 190) were finally selected in a RS. Meanwhile, data from 120 patients (ODG = 60, LDG = 60) who enrolled in a PS were analysed. Results: In the PS, the LDG group had less intraoperative blood loss, shorter time to first flatus, and shorter time to fluid diet than the ODG group. In the RS, the LDG group had less intraoperative blood loss, and a shorter postoperative hospital stay than the ODG group. In the PS, the 3-year overall survival (OS) rate was 83.3% in the LDG group and 83.2% in the ODG group (p= 0.877). In the RS, the 3-year OS rate was 68.7% in the LDG group and 66.6% in the ODG group (p = 0.752). No significant interactions were observed between the two groups and any of the variables examined, either in the PS or RS. The recurrence patterns were similar in the two groups. Furthermore, Cox regression analysis showed that surgical method (LDG/ODG) was not a prognostic factor affecting OS or DFS, either prospectively or retrospectively. Conclusions: The oncologic efficacy of laparoscopic and open distal gastrectomy for advanced GC is comparable. Well-designed RSs can be similar to small sample of PSs in assessing long-term oncologic outcomes of surgical interventions, but the short-term outcomes obtained should be treated with caution.

To determine whether laparoscopic surgery can be used in high-risk patients with gastric cancer. The clinicopathological data of 3743 patients with primary gastric adenocarcinoma, collected from January 2007 to December 2014, were retrospectively analyzed. Patients who had ≥ 1 of the following conditions were defined as high-risk patients: (1) age ≥ 80 years; (2) BMI ≥ 30 kg/m2; (3) ASA (American Society of Anesthesiologists) grade ≥ 3; or (4) clinical T stage 4 (cT4). Propensity score matching (PSM) was used to reduce confounding bias; then, we compared the short-term and long-term efficacy of laparoscopic gastrectomy (LG) with open gastrectomy (OG) in high-risk patients with gastric cancer. A total of 1296 patients were included in PSM. After PSM, no significant difference in clinicopathological data was observed between the LG group (n= 341) and the OG group (n= 341). The operative time (181.70 vs. 266.71 min, p< 0.001) and blood loss during the operation (68.11 vs. 225.54 ml, p< 0.001) in the LG group were significantly lower than those in the OG group. In the LG and OG groups, postoperative complications occurred in 39 (11.4%) and 63 (18.5%) patients, respectively, p= 0.010. Multivariate analysis showed that laparoscopic surgery was an independent protective factor against postoperative complications (p= 0.019). The number of risk factors was an independent risk factor for postoperative complications (p= 0.021). The 5-year overall survival rate in the LG group was comparable to that in the OG group (55.0 vs. 52.0%, p= 0.086). Hierarchical analysis further confirmed that the LG and OG groups exhibited comparable survival rates among patients with stages cI, pI, cII, pII, cIII, and pIII (all p> 0.05). For high-risk patients with gastric cancer, LG not only exhibits better short-term efficacy than OG but also has a comparable 5-year survival rate to OG.

To investigate oncologic efficacy of prophylactic laparoscopic superior mesenteric vein (No. 14v) lymph node (LN) dissection for lower-third gastric cancer (LTGC). We retrospectively collected data from 757 patients who underwent laparoscopic-assisted distal gastrectomy for LTGC. Of these patients, 102 underwent 14v LN dissection (14vD+ group), and the remaining 655 patients did not undergo 14v LN dissection (14vD− group). The outcomes were compared using a 1:1 propensity score matching method. After matching, 93 patients from the 14vD+ group and 93 patients from the 14vD− group with similar clinicopathological characteristics were compared. Before matching, the overall survival (OS) was similar between the two groups (P= 0.742). After matching, the OS was greater in the 14vD+ group (P= 0.025). The status of 14v dissection was not a significant prognostic factor in the survival analyses, both before and after matching. However, a stratified analysis according to the independent factors in the OS showed that the OS in the 14vD+ group was higher than that in the 14vD− group for cT2-3 patients after matching. The forest plot of OS showed that after matching the 14vD+ group had a significantly higher 3-year OS rate than the 14vD− group in cT2-3 patients. The distribution of the therapeutic index demonstrated that the index of 14v LN was similar to those of Nos. 1, 7, 8a, 9, and 11p after matching. Adding laparoscopic 14v dissection for laparoscopic-assisted radical distal gastrectomy was safe and might improve the OS for clinically advanced LTGC without serosal invasion.

Few studies have evaluated the outcomes of laparoscopic-assisted total gastrectomy (LATG) for Siewert type II and III adenocarcinoma of the esophagogastric junction (AEG). Thus, aim of this study was to investigate the surgical outcomes of LATG for Siewert type II and III AEG. Clinical data for 700 Siewert type II and III AEG patients were analyzed retrospectively. The short- and long-term outcomes were compared between the matched groups using a propensity score matching method. Before matching, the comorbidities, Siewert classifications and tumor invasion depths significantly differed between the LATG and open total gastrectomy (OTG) groups. After matching, the clinicopathologic characteristics were well balanced between the two groups. In addition, after matching, decreases in the operative time, amount of blood loss, time to resumption of a semifluid diet, and length of hospital stay and an increased number of lymph nodes (LNs) retrieved were observed in the LATG group compared with the OTG group. Further, a significantly higher 3-year overall survival rate (81.3 vs 66.4%; P= 0.011) and disease-free survival rate (77.5 vs 63.8%; P= 0.040) were observed for the Siewert type II AEG patients in the LATG group compared with those in the OTG group; however, the survival rates were similar for the Siewert type III AEG patients in the two groups (P= 0.853 and P= 0.844, respectively). LATG is associated with better short-term outcomes for Siewert type II and III AEG. In addition, it may result in an increased number of retrieved LNs and better long-term survival for Siewert type II AEG patients in particular.

In this study, we evaluated the short-term outcomes following three-dimensional (3D) or two-dimensional (2D) laparoscopic surgery for patients with gastric cancer. There is a lack of prospective evidence regarding the safety and efficacy of 3D versus 2D laparoscopic surgery for patients with gastric cancer. Therefore, we conducted a phase III single-center, prospective, randomized, controlled trial to compare 3D and 2D laparoscopic surgery for patients with gastric cancer. We compared operation time, intraoperative blood loss, number of lymph node dissections, morbidity, and mortality between the 3D and 2D groups following laparoscopic surgery for gastric cancer. The study is registered at ClinicalTrials.gov with ID number NCT02327481. A total of 228 patients were randomized (3D group 115 cases; 2D group 113 cases) between January 1, 2015 and September 1, 2015. Seven patients who underwent exploratory operations were excluded. Finally, a total of 221 patients were analyzed (3D group 109 cases, 2D group 112 cases). There were no significant differences between the two groups regarding the clinical pathological characteristics, operating time (3D vs. 2D, 184 ± 36 vs. 178 ± 37 min, P= 0.288), number of lymph node dissections (36 ± 14 vs. 37 ± 13, P= 0.698), time to first ambulation (2.27 ± 1.60 vs. 2.04 ± 0.84, P= 0.18), flatus (3.89 ± 1.49 vs. 3.69 ± 1.12, P= 0.255), liquid diet (4.88 ± 1.88 vs. 4.79 ± 1.57, P= 0.684), or duration of postoperative hospital stay (12.52 ± 4.83 vs. 12.63 ± 7.32, P= 0.903). The postoperative complication rates of the 3D and 2D groups were 18.3 and 16.1%, respectively, P= 0.723. No patients died during the postoperative hospital stay. However, the intraoperative blood loss in the 3D group was significantly lower than the 2D group (58 ± 75 vs. 78 ± 72 ml, P= 0.047). There was no significant difference in operation time and number of lymph node harvested between the 3D and 2D groups; however, 3D laparoscopic surgery may reduce the intraoperative blood loss compared to 2D procedure. Therefore, we conclude that this trial is safe and is thus ongoing.

Comorbidity is a predictor of postoperative complications in gastrectomy. However, it remains unclear which comorbidities are predictors of postoperative complications in gastric cancer patients who have undergone laparoscopy-assisted total gastrectomy (LATG). The purpose of this study was to evaluate the effect of comorbidities on the surgical outcomes of patients with gastric cancer after LATG. We retrospectively collected data on 1657 gastric cancer patients who underwent LATG between January 2008 and December 2015. We investigated the incidences, types, and risk factors for postoperative complications after LATG. Patients were enrolled in analysis to evaluate the effects of comorbidities on postoperative complications. The number of postoperative complications was associated with the number of comorbidities in the gastric cancer patients according to the operative period. Of the 1657 patients included in this study, 714 (43.1 %) had one or more comorbidities. Postoperative complications occurred in 283 patients (17.1 %), and 6 patients (0.4 %) died during hospitalization. With an increasing number of comorbidities, the incidence of local and systemic complications also increased. Univariate and multivariate analyses revealed that comorbidity was a predictive risk factor for local complications (OR 1.204, 1.014–1.431) and systemic complications (OR 1.237, 1.039–1.474). Diabetes mellitus, anemia, pulmonary disease, and renal dysfunction were found to be associated with postoperative complications, including abdominal bleeding, anastomotic leakage, and pneumonia. Our study has revealed that comorbidities could be a predictive risk factor for postoperative complications after LATG. Surgeons should carefully assess patients with full perioperative attention to some specific types of comorbidities.

To investigate the incidence of and factors associated with postoperative complications and failure to rescue following laparoscopic and open gastrectomy for gastric cancer. We analyzed the records of 4124 patients who underwent a laparoscopic or open gastrectomy for gastric cancer. One-to-one propensity score matching was performed to compare the difference between the two groups. A total of 4124 patients were included in the study, 627 of whom (15.2 %) developed postoperative complications. Postoperative deaths occurred in 23 (0.6 %) patients with serious complications. In the propensity score matching analysis with 1361 pairs, no significant differences in the rates of overall complications (14.2 vs. 16.5 %, p= 0.093) were observed between laparoscopic and open gastrectomy group. In-hospital mortality decreased in patients who underwent laparoscopic gastrectomy compared to patients who underwent open gastrectomy (0.3 vs. 1.2 %, p= 0.004). Failure to rescue rates were lower in patients who underwent laparoscopic gastrectomy (2.1 vs. 7.6 %, p= 0.008). Multivariate analysis showed that older age, tumor location, TNM stage classification, extent of gastric resection, operative time and intra-operative blood loss were adverse risk factors for postoperative complications. Laparoscopic gastrectomy was found to be a protective factor for failure to rescue. Complications associated with failure to rescue included abdominal bleeding, anastomotic leakage and cardiac events. In-hospital mortality increased as the number of complications per patient increased. Assuming equal competence with open and laparoscopic approaches of a surgeon, the proportion of patients with postoperative complications were similar among those who underwent laparoscopic gastrectomy compared to patients who underwent open gastrectomy. However, when complications occurred, patients with open gastrectomy were more likely to die.

The evidence regarding the long-term results of laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPL) has only been rarely reported. The aim of this study was to investigate the feasibility and oncologic efficacy of LSPL for locally advanced proximal gastric cancer. From May 2007 to December 2012, we prospectively collected and retrospectively analyzed the data of 548 patients who underwent laparoscopic radical total gastrectomy due to proximal gastric cancer. The patients were grouped according to spleen-preserving splenic hilar lymphadenectomy (200 in the D2 group and 348 in the D2-group). The short- and long-term outcomes were compared between the two groups after propensity score matching. Before matching, TNM stages were significantly different between the D2 and D2-groups. After propensity score matching, the two groups were well balanced in clinicopathologic characteristics. After matching, the time for lymph node dissection was longer in the D2 group, but a greater number of lymph nodes were dissected; the estimated blood loss, time to first flatus and duration of hospital stay were similar in the two groups. Furthermore, no significant differences in morbidity and mortality were found. Before matching, the 3-year overall survival (OS) and disease-free survival (DFS) rates of the D2 group were comparable with those of the D2-group (62.4 vs. 57.7 %, p= 0.076). After matching, the 3-year OS remained comparable, but the D2 group showed significantly longer 3-year DFS (61.6 vs. 53.7 %, p= 0.034). Stratified analysis showed that, in stage III patients, the D2 group had better 3-year DFS. Multivariate Cox regression showed that age (p= 0.003), operation (p= 0.001) and pN stage (p< 0.001) were independent prognostic factors. LSPL is a safe and feasible procedure, and patients with stage III proximal gastric cancer might obtain higher 3-year DFS rates.

The purpose of this study was to evaluate the risk factors that influence the difficulty of performing laparoscopic spleen-preserving splenic hilar lymph node dissection (SHLND) for gastric cancer and to establish a simple and effective scoring system to predict the surgical difficulty preoperatively. Between January 2011 and December 2013, we prospectively collected and retrospectively analyzed the medical records of 317 patients with upper- or middle-third gastric cancer who underwent laparoscopic spleen-preserving SHLND. Univariate and multivariate analyses were performed to determine the independent predictors for surgical difficulty based on the operation time during spleen-preserving SHLND. A logistic regression model was used to identify determinant variables and construct a predictive difficulty scoring system. Multivariate analysis showed that gender, body mass index (BMI), number of splenic lobar arteries (SLAs), and type of SLA were independently predictive factors of operation time. According to these factors, we developed a predictive surgical difficulty scoring system and the difficulty levels are divided into 0, 1, 2, 3, and 4 points or more. Based on the relative risk, we stratified the surgical difficulty into the following three divisions: 0 low difficulty, 1–2 intermediate difficulty, and 3 points or more high difficulty. The patients with long operation time accounted for 19.6, 43.6, and 90.9 % for the three groups, respectively (p< 0.001). The area under the receiver operating characteristic curve for the logistic regression model and the simplified difficulty scoring prediction model was 0.717 and 0.715, respectively. Based on four independent risk factors, including gender, BMI, number of SLAs, and type of SLA, we developed a simple and effective scoring system to predict the difficulty of laparoscopic spleen-preserving SHLND preoperatively. This novel scoring system might aid surgeons with different experience in performing operations at different levels of difficulty.

A scoring system allows risk stratification of morbidity might be helpful for selecting risk-adapted interventions to improve surgical safety. Few studies have been designed to develop scoring systems to predict SSIs after laparoscopic gastrectomy for gastric cancer. We analyzed the records of 2364 patients who underwent laparoscopic gastrectomy for gastric cancer. A logistic regression model was used to identify the determinant variables and develop a predictive score. There were 2364 patients, of whom 131 (5.5 %) developed overall SSIs, 33 (1.4 %) developed incisional SSIs, and 98 (4.1 %) developed organ/space SSIs. No significant risk factor was associated with incisional SSIs. A multivariate analysis showed the following adverse risk factors for organ/space SSIs: BMI ≥ 25 kg/m2, intraoperative blood loss ≥75 ml, operation time ≥240 min, and perioperative transfusion. Each of these factors contributed 1 point to the risk score. The organ/space SSIs rates were 1.8, 3.9, 9.9, and 39.0 % for the low-, intermediate-, high-, and extremely high-risk categories, respectively (p< 0.001). The area under the receiver operating characteristic curve for the score of organ/space SSIs was 0.734. There were no statistically significant differences between the observed and predicted incidence rates for organ/space SSIs in the validation set. This validated and simple scoring system could accurately predict the risk of organ/space SSIs after laparoscopic gastrectomy for gastric cancer. The score might be helpful in the selection of risk-adapted interventions to decrease the incidence rates of organ/space SSIs.

Laparoscopic spleen-preserving total gastrectomy (LSPTG) for gastric cancer is only performed at a few specialized institutions and carries the risk of major perioperative complications (MPCs) that may require reoperation and impair recovery. However, the predictors of such events remain largely unknown. Prospectively collected data from 325 consecutive patients undergoing LSPTG at a single institution from June 2011 to February 2014 were analyzed to determine the preoperative factors that correlated with MPCs. The rates of MPCs were assessed, and a score model was developed to identify preoperative variables associated with MPC. Of the 325 LSPTG cases, the following types of MPCs were observed in 15 (4.6 %) patients: intraoperative splenic hilar vascular injury (n= 1); intraoperative splenic parenchymal injury (n= 5); intraoperative splenic infarction (n= 1); intraabdominal abscess that required radiological intervention [not under general anesthesia (n= 2)]; intra-abdominal bleeding that required reoperation under general anesthesia (n= 2); anastomotic hemorrhage that required reoperation under general anesthesia (n= 2); and death (n= 2). Three independent variables were correlated with MPCs in the multivariate analysis: body mass index (BMI) ≥25 kg/m2(odds ratio [OR] 3.992, 95 % confidence interval [CI] 1.210–13.175), tumor located at the greater curvature (OR 3.922, 95 % CI 1.194–12.880), and No.10 LN metastases (OR 4.418, 95 % CI 1.250–13.770). A risk score consisting of one point for each preoperative risk factor (BMI ≥ 25 kg/m2or tumor location in the greater curvature), resulting in an overall score of 0–2 points for each patient, predicted an increased risk of MPCs. BMI, tumor location, and No.10 LN metastases were significantly associated with increased rates of MPCs. A simple, clinically relevant scoring system based on two preoperative variables was clinically useful in predicting MPC risk in patients undergoing LSPTG.