Laparoscopic vs Open Distal Gastrectomy for Locally Advanced Gastric Cancer

Abstract

IMPORTANCEThe long-term safety of laparoscopic distal gastrectomy for locally advanced gastric cancer (AGC) remains uncertain given the lack of 5-year follow-up results.OBJECTIVE To compare the 5-year follow-up results in patients with clinically AGC enrolled in the Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS)-02 randomized clinical trial who underwent laparoscopic or open distal gastrectomy. DESIGN, SETTING, AND PARTICIPANTSThe KLASS-02, a multicenter randomized clinical trial, showed that laparoscopic surgery was noninferior to open surgery for patients with locally AGC. The present study assessed the 5-year follow-up results, including 5-year overall survival (OS) and relapse-free survival (RFS) rates and long-term complications, in patients enrolled in KLASS-02. From November 21, 2011, to April 29, 2015 aged 20 to 80 years diagnosed preoperatively with locally AGC were enrolled. Final follow-up was on June 15, 2021. Data were analyzed June 24 to September 9, 2021. INTERVENTIONS Patients were treated with R0 resection either by laparoscopic gastrectomy or open gastrectomy as the full analysis set of the KLASS-02 trial. MAIN OUTCOMES AND MEASURES Five-year OS and RFS rates, recurrence patterns, and long-term surgical complications were evaluated. RESULTS This study enrolled a total of 1050 patients. A total of 974 patients were treated with R0 resection; 492 (50.5%) in the laparoscopic gastrectomy group (mean [SD] age, 59.8 [11.0] years; 351 men [71.3%]) and 482 (49.5%) in the open gastrectomy group (mean [SD] age, 59.4 [11.5] years; 335 men [69.5%]). In patients who underwent laparoscopic and open distal gastrectomy, the 5-year OS (88.9% vs 88.7%) and RFS (79.5% vs 81.1%) rates did not differ significantly. The most common types of recurrence were peritoneal carcinomatosis (73 of 173 [42.1%]), hematogenous metastases (36 of 173 [20.8%]), and locoregional recurrence (23 of 173 [13.2%]), with no between-group differences in types of recurrence at each cancer stage. The correlation between 3-year RFS and 5-year OS at the individual level was highest in patients with stage III gastric cancer (ρ = 0.720). The late complication rate was significantly lower in the laparoscopic than in the open surgery group (32 of 492 [6.5%] vs 53 of 482 [11.0%]). The most common type of complication in both groups was intestinal obstruction (13 of 492 [2.6%] vs 24 of 482 [5.0%]). CONCLUSIONS AND RELEVANCEThe 5-year outcomes of the KLASS-02 trial support the 3-year results, which is the noninferiority of laparoscopic surgery compared with open gastrectomy for locally AGC. The laparoscopic approach can be recommended in patients with locally AGC to achieve the benefit of low incidence of late complications.

Improved survival after laparoscopic compared to open gastrectomy for advanced gastric cancer: a Swedish population-based cohort study

“…Short-term benefits include reduced postoperative morbidity and earlier recovery, which usually also translate into shorter hospital stay [11][12][13][14]. Long-term outcomes have also been reported in recent years, showing that laparoscopic and open surgery are equivalent in terms of oncological safety and survival [15,16]. The issue is that for the most part, the body of evidence on gastric cancer surgery is generated in high-incidence East Asian countries.…”

Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach

“…The KLASS-02 study reported a lower complication rate in the laparoscopic group than in the open group (6.5% vs. 11.0%, P=0.01). The 5-year OS of LDG (88.9%) was not inferior to that of ODG (88.7%, P=0.30) [ 314 315 ] ( Fig. 11 ).…”

Critical Analysis of the Klass-02 Randomized Clinical Trial—Reply

“…In Reply We appreciate the interest expressed by Pohekar and Shinde in our article . They raised 3 issues: (1) the survival rates were higher than those in the American Joint Committee on Cancer 8th edition, (2) a high proportion of patients with pathologic stage 1 cancer was included, and (3) adjuvant chemotherapy was given instead of perioperative chemotherapy.…”