Comparison of Short-Term Postoperative Outcomes in Totally Laparoscopic Distal Gastrectomy Versus Laparoscopy-Assisted Distal Gastrectomy

The incidence of gastric cancer in Korea was reported as 60.3 per 100,000 inhabitants in 2010, and the age-standardized incidence rate has been steady over the last decade. However, the 5-year relative survival rate has markedly improved from 42.8% to 67.0% primarily because of early detection via the national screening policy.1 As the incidence of early gastric cancer (EGC) is increasing, minimally invasive surgery using a laparoscopic approach has become a widely used procedure for the treatment of EGC in Korea. In addition, several centers are performing totally laparoscopic distal gastrectomy (TLDG) with intracorporeal reconstruction as the treatment of choice for distal EGC.

TLDG was first introduced in 1992 by Goh et al.2 demonstrating intracorporeal Billroth II anastomosis using laparoscopic linear staplers. Since then, the laparoscopic technique has steadily improved, and more effective staplers are being developed. However, to date, TLDG is not commonly performed because of the steep learning curve and concerns with the technical feasibility of the procedure. Here, we present our experiences and short-term surgical outcomes after TLDG with various types of intracorporeal anastomosis and compare TLDG with laparoscopy-assisted distal gastrectomy (LADG).

Since the introduction of LADG for EGC, many trials have evaluated the oncological feasibility and safety of LADG compared to those of conventional open distal gastrectomy (ODG). A prospective randomized multicenter study by Kim et al.9 suggested that LADG showed no significant difference in the morbidity and mortality compared with ODG. LADG showed similar 5-year disease-free survival and 5-year overall survival rates compared to those with ODG in the treatment of EGC. Additionally, LADG was associated with milder complications than ODG, based on an evaluation using the Accordion Severity Grading System of Postoperative Complications.10 Another randomized clinical trial revealed that LADG had contributed to improved quality of life in patients at the 3-month follow-up.11

Although TLDG was first introduced by Goh et al.2 in 1992, there is limited evidence regarding oncologic outcomes and its feasibility owing to the difficulty in skill acquisition and in experience. Previous studies have reported that at least 20~40 cases are needed to stabilize the surgical procedure for TLDG and to overcome the initial learning curve even for surgeons with sufficient experience in laparoscopic gastrectomy.12, 13, 14 Accordingly, even in Korea where the prevalence of EGC is high, only a few centers are performing TLDG for EGC. Only several studies have reported TLDG outcomes. Gao et al.15 published a meta-analysis showing that TLDG significantly reduced bleeding, time to first flatus, and postoperative hospital stay and can be considered a useful technique for patients with gastric cancer compared with LADG. Ikeda et al.16 suggested that TLDG had several advantages over LADG including smaller wounds, less invasiveness, and better feasibility of secure ablation. Song et al.17 reported that, compared with LADG, TLDG was more expensive but resulted in a shorter bowel recovery time, measured as the time to first flatus.

The present study showed results consistent with those of previous studies demonstrating that TLDG has advantages over LADG in terms of operative time, estimated blood loss, and postoperative hospital stay. The length of postoperative hospital stay in the TLDG group was shorter than that in the LADG group. This result suggests that the TLDG method may be less invasive, which is represented by smaller incisions and reduced manipulation. Furthermore, the shorter operative time and reduced estimated blood loss observed in the TLDG group support this postulation. The incidence of postoperative complications was similar between the groups, although the preoperative surgical risk, which is represented by the ASA classification, was higher in the TLDG group. These findings clearly suggest that TLDG has the benefit of earlier recovery over LADG, even in patients with a relatively high surgical risk.

In our study, the median PRM in TLDG was significantly longer than that in LADG despite the fact that the proportion of upper-middle lesions in the TLDG group was larger than that in the LADG group with statistical significance. This could have been influenced by the difference in reconstruction type and method between the groups. In LADG, the most frequently used reconstruction was Billroth I anastomosis (51.3%), followed by Billroth II with Braun anastomosis (36.8%). On the other hand, Billroth II with Braun anastomosis (35.1%) and Roux-en-Y anastomosis (64.9%) were used in most of the cases during TLDG because they were technically less demanding for the operating surgeon. In LADG cases, it is necessary to retain enough length of the remnant stomach to perform the extracorporeal anastomosis without difficulty. Furthermore, in LADG, the surgeon tended to secure a shorter proximal safe margin to reduce the tension in the anastomosis of the Billroth I reconstruction. Conversely, in TLDG, the surgeon tended to use a longer PRM because the EGC lesion could not be localized laparoscopically with palpation, resulting in the possibility of an unsatisfactory PRM even though simultaneous intraoperative endoscopy was used. Furthermore, the long remnant stomach in gastrojejunal anastomosis is not needed during intracorporeal anastomosis. As a result, TLDG could allow relatively sufficient and safe proximal margins, which could be easily applied for lesions located in the higher portion of the stomach, compared with LADG.

There are several limitations in the current study. First, surgeries were performed consecutively by a single surgeon, and TLDG was adopted relatively later than LADG. TLDG was first performed after gaining sufficient experience with 75 LADG cases, which may have resulted in a bias in the present study considering the learning curve associated with laparoscopic surgery. Second, different reconstruction types were used among the groups, which may have resulted in different surgical outcomes according to the reconstructive type. However, the number of enrolled patients in the present study was too small to conduct subgroup analyses based on the reconstruction types. Lastly, this study was retrospective in design, which may have introduced bias in the analyses. Detailed information about the surgical procedure and postoperative course, such as the time required for reconstruction, time to first flatus, and postoperative analgesic use, were also missing. A well-designed prospective study evaluating these parameters would be necessary to elucidate clearly the real benefits of intracorporeal anastomosis in laparoscopic distal gastrectomy.

In conclusion, TLDG is technically feasible and has several advantages over LADG, such as less intraoperative blood loss, shorter operative times and hospital stay, more sufficient PRM, and better cosmesis. TLDG could bea useful surgical technique for patients with EGC between the mid-upper body and the prepyloric area of the stomach when performed by a surgeon experienced in laparoscopic gastrectomy.