Department of General Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, Guangdong, China.
J Gastrointest Surg. 2019 Jul;23(7):1349-1361. doi: 10.1007/s11605-018-4008-2. Epub 2018 Nov 26.
The long-term outcomes of laparoscopic gastrectomy (LG) versus open gastrectomy (OG) for gastric cancer (GC) remain obscure, especially for advanced cancer and disease affecting the upper stomach and in older patients. This study aimed to comprehensively assess the long-term efficacy of LG for GC using a large prospective database.
Totally, 1877 consecutive patients (1186 receiving LG and 691 OG) operated in 2004-2016 were analyzed, with a median follow-up of 63 months. Association of LG versus OG with disease-specific survival (DSS) and disease-free survival (DFS) overall and in various subgroups were investigated using multivariable Cox regression. Propensity score matching (PSM) was performed for sensitivity analysis.
Before PSM, overall, there was no significant association of LG versus OG with survival after multivariable adjustment; however, in subgroup analyses, LG was associated with superior DSS in patients aged ≥ 70 years and those with upper GC. No significant associations regarding DFS were observed overall or in stratifications. PSM analyses revealed that LG was associated with better DSS also in patients aged ≥ 70 years (hazard ratio (HR) = 0.33, 95% confidence interval (CI) = 0.15-0.72) and in those with upper GC (HR = 0.51, 95% CI = 0.29-0.91), and with better DFS in those with upper GC (HR = 0.60, 95% CI = 0.37-0.99). Multivariable analysis showed that age, hepatitis B, performance status, tumor histology, stage, and vascular invasion were significantly associated with post-LG survival. LG-specific nomograms were then constructed with concordance indexes of 0.814 (DSS) and 0.809 (DFS) and excellent calibration.
In this large institutional analysis, while LG for GC was associated with DSS and DFS similar to those for OG overall, non-inferior LG-associated survival especially DSS was observed in some subgroups rarely investigated in prospective or randomized settings. There could still be biases even after PSM due to confounders not accounted for in this observational study. However, these findings offer novel hypotheses for further validation.
腹腔镜胃切除术（LG）与开腹胃切除术（OG）治疗胃癌（GC）的长期结果仍不清楚，尤其是对于晚期癌症和影响上胃的疾病以及老年患者。本研究旨在使用大型前瞻性数据库全面评估 LG 治疗 GC 的长期疗效。
分析了 2004 年至 2016 年间接受手术的 1877 例连续患者（1186 例接受 LG，691 例接受 OG），中位随访时间为 63 个月。使用多变量 Cox 回归分析 LG 与 OG 与疾病特异性生存率（DSS）和无病生存率（DFS）的关系，以及在各种亚组中的关系。进行倾向评分匹配（PSM）以进行敏感性分析。
在 PSM 之前，多变量调整后，LG 与 OG 与生存之间没有显著关联；然而，在亚组分析中，LG 与≥70 岁患者和上胃 GC 患者的 DSS 更高相关。在整体或分层中均未观察到与 DFS 相关的显著关联。PSM 分析显示，LG 与≥70 岁患者的 DSS 也更好相关（风险比（HR）=0.33，95%置信区间（CI）=0.15-0.72）和上胃 GC 患者（HR=0.51，95%CI=0.29-0.91），与上胃 GC 患者的 DFS 也更好相关（HR=0.60，95%CI=0.37-0.99）。多变量分析显示，年龄、乙型肝炎、表现状态、肿瘤组织学、分期和血管侵犯与 LG 后生存显著相关。然后构建了 LG 特异性列线图，其 DSS 的一致性指数为 0.814，DFS 的一致性指数为 0.809，且校准良好。
在这项大型机构分析中，虽然 LG 治疗 GC 的 DSS 和 DFS 与 OG 相似，但在一些前瞻性或随机研究中很少研究的亚组中，LG 相关的非劣效生存，尤其是 DSS，观察到更好的生存。即使在 PSM 后，由于本观察性研究未考虑混杂因素，仍可能存在偏倚。然而，这些发现为进一步验证提供了新的假设。
