In this study, surgical outcomes and prognoses were compared between LATG and TLTG groups. After PSM, the TLTG group had less blood loss, decreased frequency of analgesic use, and shorter duration of analgesic use. Moreover, in terms of postoperative complications, the TLTG group head significantly lower rates of intestinal obstruction and surgical site infection, compared with the LATG group. According to multivariate analysis, larger tumor size and advanced pathological stage were independent risk factors for postoperative complications. However, OS did not significantly differ between the two groups.
Surgical outcomes such as operation time, number of retrieved lymph nodes, number of metastatic lymph nodes, time to diet, and duration of hospitalization were not significantly different between our LATG and TLTG groups. However, estimated blood loss, frequency of analgesic use, and duration of analgesic use were superior in the TLTG group. In a review of studies involved TLTG, Umemura et al. concluded that it has advantages in terms of estimated blood loss or postoperative recovery [16]. TLTG has also has the advantage of less intraoperative traction, which reduces the risk of injury to tissues near organs and incision sites [17]. When LATG is performed, the stomach and abdominal esophagus must be mobilized from the esophageal hiatus to ensure that the operating field is adequate; this mobilization is achieved via mini-laparotomy, using a flat retractor [18]. We usually make a 10-cm midline incision during LATG to create an esophagojejunostomy using a circular stapler. After the incision line has been made, an assistant typically creates traction to ensure sufficient space for dissection and anastomosis. However, this procedure may result in tissue injury, followed by intraoperative bleeding. Moreover, s long incisional wound and intraoperative traction are likely to cause postoperative pain, thus requiring the use of more analgesic in LATG patients.
There were no significant differences in postoperative medical complications such as pulmonary complications or cardiovascular diseases between the LATG and TLTG groups in the present study. Moreover, postoperative surgical complications including anastomotic bleeding, anastomotic leakage, intraabdominal abscess, and intraabdominal bleeding did not significantly differ between the two groups. However, the incidences of surgical site infection and intestinal obstruction were significantly higher in the LATG group. Several studies revealed that female sex, older age, high BMI, diabetes mellitus, open gastrectomy, and a longer operation time were risk factors for surgical site infection [19, 20, 21, 22]. Female patients tend to have more subcutaneous fat, which might increase the risk of superficial incisional site infection [19]. In the present study, there were more female patients in the LATG group than in the TLTG group, although the difference was not statistically significant. Additionally, the LATG group included more patients with a BMI of > 25 kg/m2 and had longer operation times, although these differences also were not statistically significant. The performance of esophagojejunostomy after mini-laparotomy in the LATG group could have affected the incidence of surgical site infection. Longer operative time and frequent use of opiates may be risk factors for postoperative intestinal obstruction [23]. Moreover, a meta-analysis revealed that laparoscopic surgery reduced the likelihood of intestinal obstruction [24]. Laparoscopic surgery is less traumatic than open surgery, and could promote more rapid recovery of postoperative bowel function [25]. The levels of circulating cytokines and C-reactive protein, which reflect the degree of systemic inflammation, are lower in laparoscopic surgery [26]. LATG is not a totally laparoscopic procedure, and it may cause more tissue trauma than TLTG. Furthermore, in the present study, thefrequency and duration of analgesia were significantly greater in the LATG group, which might have influenced the incidence of intestinal obstruction.
Our multivariate analysis showed that advanced pathological stage and tumor size > 5 cm were risk factors for postoperative complications. A multi-institutional retrospective analysis demonstrated that older age, a larger number of comorbidities, larger tumor size, and more advanced disease were risk factors for postoperative abdominal complications [27]. Additionally, a case-control study revealed that male sex, clinical stage II or III disease, and total or proximal gastrectomy were risk factors for postoperative complications [28]. These results are consistent with the findings in the present study. Patients with advanced pathological stage tend to show greater immunosuppression because tumor immune tolerance is induced during tumor progression [29]. A reduction in cytokine production is more likely prevalent in such patients, indicating that immune function is reduced in advanced cancer stage patients [30]. This immunosuppressed condition increases vulnerability to postoperative complications such as abdominal abscess and surgical site infection.
Regardless of pathological stage, OS did not significantly differ between LATG and TLTG groups in the present study. This finding indicates that patient prognosis is not influenced by the surgical method used in each pathological stage. Several studies comparing surgical outcomes between open total gastrectomy and LATG showed that long-term survival was not affected by the type of surgery performed in the various pathological stages [31, 32]. Few studies have compared OS between LATG and TLTG patients, although one article reported no significant difference in 3-year OS between TLTG and LATG groups, consistent with our findings [32]. In the present study, 5-year OS did not differ between the LATG and TLTG groups regardless of pathological stage, including stage III gastric cancer.
This study had several limitations. First, it was a retrospective study involving only two institutions, and its sample size was small. Furthermore, the procedure was selected on the basis of the operating surgeons’ preferences and each patient’s characteristics, which could have led to selection bias. Therefore, a randomized clinical trial is necessary to confirm our findings, although we sought to limit bias via PSM. Second, because LATG and TLTG were performed in different time periods, laparoscopic surgical skill might have differed between the two groups. Although this time difference was unavoidable, our analysis minimized bias, by including all patients in TLTG patients consecutively recruited from the first case onward, along with all patients in the LATG group who were recruited during the same period. Despite these limitations, this study is notable for comparing long-term prognoses between LATG and TLTG.
In conclusion, compared with LATG, TLTG is associated with better surgical outcomes and fewer postoperative surgical complications in patients with gastric cancer. Moreover, TLTG is comparable with LATG in terms of long-term outcomes, such as OS. The present study provides useful reference data for future randomized clinical trials and may encourage more widespread use of totally laparoscopic surgery in the management of gastric cancer.