Abstract: Objective:To compare the clinical efficacies of totally laparoscopic and laparoscopyassisted radical total gastrectomies.
Methods:The retrospective cohort study was conducted. The clinicopathological data of 373 patients with gastric cancer who underwent totally laparoscopic or laparoscopyassisted radical total gastrectomies from the 7 medical centers in China (82 patients in the Affiliated Hospital of Qinghai University, 80 in the Traditional Chinese Medicine Hospital of Guangdong Province, 60 in the First Affiliated Hospital of Xiamen University, 51 in the Hangzhou First People′s Hospital, 46 in the First Affiliated Hospital of Xi′an Jiaotong University, 30 in the Second Affiliated Hospital of Jilin University and 24 in the Xijing Hospital of the Fouth Military Medical University) between January 2015 and December 2016 were collected. Of 373 patients, the 183 and 190 patients were respectively divided into the totally laparoscopic group (undergoing totally laparoscopic radical total gastrectomy) and laparoscopyassisted group (undergoing laparoscopyassisted radical total gastrectomy), including 63 and 19 in the Affiliated Hospital of Qinghai University, 36 and 44 in the Traditional Chinese Medicine Hospital of Guangdong Province, 25 and 35 in the First Affiliated Hospital of Xiamen University, 20 and 31 in the Hangzhou First People′s Hospital, 10 and 36 in the First Affiliated Hospital of Xi′an Jiaotong University, 17 and 13 in the Second Affiliated Hospital of Jilin University, 12 and 12 in the Xijing Hospital of the Fouth Military Medical University. Routine fiveport method was applied for laparoscopic radical total gastrectomy and D₂ lymphadenectomy. RouxenY anastomosis was applied for digestive tract reconstruction, and digestive tract reconstruction was performed under laparoscopy in the totally laparoscopic group and via upper abdominal median incision in the laparoscopyassisted group. Observation indicators: (1) operation and postoperative situations; (2) followup and survival situations. Followup using outpatient examination and telephone interview was performed to detect the postoperative overall survival and tumor recurrence or metastasis up to March 2017. Measurement data with normal distribution were represented as ±s. Comparison between the groups was analyzed by the t test. Measurement data with skewed distribution were represented as M (range). Comparisons of count data were analyzed using the chisquare test and Fisher exact probability.
Results:(1) Operation and postoperative situations: all the patients in the 2 groups underwent successful operations, without perioperative death. Esophagojejunostomy methods of 183 patients in totally laparoscopic group: conventional circular stapler method were performed in 28 patients, antipuncture circular staplar method in 6 patients, OrVil TM method in 5 patients, functional endtoend esophagojejunostomy method in 65 patients and peristalsis sidetoside esophagojejunostomy method in 79 patients. Conventional circular stapler method was applied to 190 patients in the laparoscopyassisted group. Operation time, time of esophagojejunostomy, length of assisted incision, using time of analgesics and expenses of digestive tract reconstruction were (238±55)minutes, (29±9)minutes, (5.1±1.1)cm, (2.2±1.0)days, (18 332±2 141)yuan in the totally laparoscopic group and (217±39)minutes, (26±7)minutes, (7.8±2.0)cm, (2.7±0.9)days, (16 237±1 923)yuan in the laparoscopyassisted group, respectively, with statistically significant differences between the 2 groups (t=4.324, 3.455,-16.835,-5.561, 9.949, P<0.05). The cases with postoperative overall complications, anastomosis leakage, anastomosis stricture, anastomosis bleeding and expenses of esophagojejunostomy were respectively 24, 9, 7, 5, (9 668±2 814)yuan in the totally laparoscopic group and 24, 8, 9, 6, (9 331±2 067)yuan in the laparoscopyassisted group, with no statistically significant difference between the 2 groups (x²=0.036, 0.107, 0.189, 0.059, t=1.322, P>0.05). All the patients with postoperative complications were cured by symptomatic treatment. (2) Followup and survival situations: of 373 patients, 336 were followed up for 4-26 months, with a median time of 13 months, including 166 in the totally laparoscopic group and 170 in the laparoscopyassisted group. During the followup, cases with overall survival, tumor recurrence and tumor metastasis were respectively 150, 10, 16 in the totally laparoscopic group and 154, 9, 16 in the laparoscopyassisted group (10 and 9 patients in the totally laparoscopic and laparoscopyassisted groups with simutaneous tumor recurrence and metastasis), showing no statistically significant difference between the 2 groups (x²=0.075, 0.010, P>0.05).
Conclusions:Total laparoscopic and laparoscopyassisted radical total gastrectomies are safe and feasible, with equivalent overall outcomes and effects of esophagojejunostomy. Compared with laparoscopyassisted radical total gastrectomy, the postoperative pain time of patients in total laparoscopic radical total gastrectomy is less, but there are longer time of esophagojejunostomy and higher expenses of digestive tract reconstruction.