Totally laparoscopic total gastrectomy using the modified overlap method and conventional open total gastrectomy: A comparative study

Table 1 Patient clinical characteristics

Variable	Total set (n = 282)		P value	SD	PSM set (1:1) (n = 122)		P value	SD
	TLTG (n = 151)	OTG (n = 131)			TLTG (n = 61)	OTG (n = 61)
Age (yr)	60.74 ± 11.55	59.11 ± 11.02	0.231	0.144	58.30 ± 11.26	58.70 ± 10.65	0.841	0.037
Gender			0.257	0.136			0.847	0.035
Male	94 (62.25)	90 (68.70)			40 (65.57)	41 (67.21)
Female	57 (37.75)	41 (31.30)			21 (34.43)	20 (32.79)
BMI (kg/m²)	24.57 ± 3.25	23.69 ± 3.21	0.023	0.273	24.01 ± 2.98	23.98 ± 2.73	0.957	0.010
ASA score			0.859	0.044			0.885	0.073
I	30 (19.87)	26 (19.85)			13 (21.31)	14 (22.95)
II	114 (75.50)	97 (74.05)			46 (75.41)	44 (72.13)
III	7 (4.64)	8 (6.11)			2 (3.28)	3 (4.92)
Number of comorbidities			0.068	0.222			0.655	0.083
0-2	137 (90.73)	126 (96.18)			59 (75.41)	44 (72.13)
> 2	14 (9.27)	5 (3.82)			2 (3.28)	3 (4.92)
Combined operation			0.176	0.161			> 0.999	0
No	136 (90.07)	111 (84.73)			55 (90.16)	55 (90.16)
Yes	15 (9.93)	20 (15.27)			6 (9.84)	6 (9.84)
History of abdominal surgery			0.061	0.254			0.846	0.103
No	120 (79.47)	102 (77.86)			50 (81.97)	48 (78.69)
Minor surgery	24 (15.89)	14 (10.69)			6 (9.84)	6 (9.84)
Major surgery	7 (4.64)	15 (11.45)			5 (8.20)	7 (11.48)
Tumor size (mm, median)	31 (22, 46)	64 (36, 85)	< 0.001	0.841	39 (27, 62)	50 (28, 68)	0.865	0.028
Pathologic tumor stage			< 0.001	1.012			0.824	0.085
I	109 (72.19)	38 (29.01)			31 (50.82)	33 (54.10)
II	28 (18.54)	41 (31.30)			19 (31.15)	19 (31.15)
III	14 (9.27)	52 (39.69)			11 (18.03)	9 (14.75)

Values are expressed as mean ± SD or n (%). PSM: Propensity score matching; BMI: Body mass index; ASA score: American Society of Anesthesiologists Physical Status Classification; TLTG: Totally laparoscopic gastrectomy; OTG: Open total gastrectomy.

Table 2 Early surgical outcomes and pathologic data in patients undergoing the totally laparoscopic gastrectomy with the modified overlap method and open total gastrectomy

Variable	Total set (n = 282)		P value	PSM set (1:1) (n = 122)		P value
	TLTG (n = 151)	OTG (n = 131)		TLTG (n = 61)	OTG (n = 61)
Operative time (min)	147.68 ± 29.64	145.24 ± 35.48	0.282	147.11 ± 25.48	143.46 ± 38.09	0.351
Time to first flatus (d)	3.73 ± 0.90	4.14 ± 0.81	< 0.001	3.62 ± 0.84	4.15 ± 0.87	0.002
Time to soft diet (d)	4.99 ± 3.78	7.24 ± 6.29	< 0.001	4.62 ± 2.67	7.47 ± 7.92	0.001
Perioperative transfusion (n)			< 0.001			0.035
No	145 (96.03)	107 (81.68)		59 (96.72)	52 (85.25)
Yes	6 (3.97)	24 (18.32)		2 (3.28)	9 (14.75)
Hospital day after surgery (d)	9.96 ± 6.36	13.06 ± 11.09	< 0.001	9.62 ± 5.32	13.51 ± 10.67	< 0.001
Pick of pain score (VAS)	4 (3.92)	5 (2.51)	0.494	3 (3.16)	1 (1.05)	0.317
Pain score at postoperative day	3.19 ± 1.04	3.83 ± 1.14	< 0.001	3.23 ± 1.09	4.07 ± 1.35	< 0.001
Pain score at postoperative day 1	2.98 ± 1.07	3.76 ± 1.13	< 0.001	2.97 ± 0.87	3.77 ± 1.07	< 0.001
Pain score at postoperative day 3	2.68 ± 1.17	3.10 ± 1.28	< 0.001	2.75 ± 1.31	3.16 ± 1.27	< 0.001
Pain score at postoperative day 5	1.93 ± 1.13	2.61 ± 1.49	< 0.001	1.82 ± 1.13	2.64 ± 1.21	< 0.001
Administration of analgesics (n)	9.74 ± 8.92	16.22 ± 18.06	< 0.001	10.61 ± 11.07	16.92 ± 13.72	< 0.001
Administration of opioid (n)	2.89 ± 5.49	5.43 ± 11.51	< 0.001	3.21 ± 6.98	4.48 ± 5.15	0.031
Retrieved LN	39.53 ± 15.59	41.03 ± 15.31	0.265	38.67 ± 13.82	38.13 ± 14.52	0.713

Values are expressed as mean ± SD or n (%) or median (range). PSM: Propensity score matching; LN: Lymph node; PRM: Proximal resection margin; TLTG: Totally laparoscopic gastrectomy; OTG: Open total gastrectomy.

Table 3 Postoperative complications

Variable	Total set (n = 282)		P value	PSM set (1:1) (n = 122)		P value
	TLTG (n = 151)	OTG (n = 131)		TLTG (n = 61)	OTG (n = 61)
Early complications
No	119 (78.81)	99 (75.57)	0.518	48 (78.69)	43 (70.49)	0.317
Yes	32 (21.19)	32 (24.43)		13 (21.31)	18 (29.51)
Late complications
No	142 (94.04)	125 (95.42)	0.607	56 (91.80)	59 (96.72)	0.257
Yes	9 (5.96)	6 (4.58)		5 (8.20)	2 (3.28)
CDC			0.426			0.564
0-2	138 (91.39)	116 (88.55)		56 (91.80)	54 (88.52)
≥ 3	13 (8.61)	15 (11.45)		5 (8.20)	7 (11.48)
EJ related complications			0.090			0.270
No	148 (98.01)	123 (93.89)		59 (96.72)	56 (91.80)
Yes	3 (1.99)	8 (6.11)		2 (3.28)	5 (8.20)

Values are expressed as mean ± SD or n (%). PSM: Propensity score matching; TLTG: Totally laparoscopic gastrectomy; OTG: Open total gastrectomy; CDC: Clavien-Dindo classification; EJ: Esophagojejunostomy.

Table 4 Characteristics of the patients with esophagojejunostomy-related complications

Case	Sex	Age	Primary operation	TNMstage	Early or late	Type of complication	CDC	Treatment	Hospital day
1	F	79	TLTG	III	Early	Bleeding	5	Operation	8
2	M	65	TLTG	II	Early	Leakage	3A	Intervention	20
3	M	74	OTG	I	Early	Leakage	2	Conservative	14
4	M	74	OTG	I	Early	Bleeding	3A	Intervention	72
5	M	60	OTG	I	Early	Leakage	3A	Intervention	48
6	M	66	OTG	I	Early	Leakage	2	Conservative	25
7	M	63	OTG	I	Early	Leakage	3A	Intervention	32

TNM: Tumor-node-metastasis; CDC: Clavien-Dindo classification; F: Female; M: Male; TLTG: Totally laparoscopic gastrectomy; OTG: Open total gastrectomy.

Table 5 Univariate analysis of risk factors for overall early, Clavien-Dindo classification ≥ 3, and esophagojejunostomy-related complications

Variables	Early complications		CDC ≥ 3 complications		EJ-related complications
	OR (95%CI)	P value	OR (95%CI)	P value	OR (95%CI)	P value
Type of surgery		0.518		0.428		0.090
TLTG	1		1		1
OTG	1.202 (0.688-2.100)		1.373 (0.628-3.002)		3.209 (0.833–12.356)
Age		0.289		0.051		0.035
< 60	1		1		1
≥ 60	1.358 (0.772-2.390)		2.347 (0.997-5.525)		9.220 (1.164-73.022)
BMI		0.045		0.380		0.402
< 25	1		1		1
≥ 25	1.773 (1.012-3.109)		1.419 (0.649-3.101)		1.678 (0.500-5.633)
ASA score		0.030		0.036
1-2	1		1
3	3.224 (1.122-9.265)		3.682 (1.088-12.456)
Number of comorbidities		0.342				0.752
0-2	1				1
> 2	1.631 (0.594-4.480)				1.406 (0.170-11.599)
Combined operation		0.685		0.381		0.735
No	1		1		1
Yes	0.833 (0.346-2.008)		0.515 (0.117-2.272)		0.697 (0.086-5.618)
History of abdominal surgery		0.130		0.323
No	1		1		1
Yes	1.640 (0.864-3.111)		1.554 (0.648-3.726)		1.408 (0.362-5.478)	0.622
Tumor size		0.521		0.442		0.053
< 5 cm	1		1		1
≥ 5 cm	0.830 (0.470-1.466)	0.521	0.727 (0.323-1.638)		3.786 (0.983-14.585)
Operation time		0.225		0.605		0.805
< 150 min	1		1		1
≥ 150 min	1.414 (0.808-2.477)		1.230 (0.562-2.692)		1.165 (0.347-3.912)
Retrieved lymph node		0.714		0.662		0.246
< 30	1		1		1
≥ 30	0.888 (0.471-1.676)		1.235 (0.480-3.181)		3.416 (0.429-27.170)
Pathologic tumor stage		0.418		0.864		0.875
I	1		1		1
II	0.666 (0.328-1.351)		1.246 (0.497-3.126)		0.701 (0.138-3.568)
III	0.704 (0.346-1.431)		0.950 (0.348-2.592)		1.119 (0.27-4.617)

Values are expressed as mean ± SD or n (%). TLTG: Totally laparoscopic total gastrectomy; OTG: Open total gastrectomy; CDC: Clavien-Dindo classification; EJ: Esophagojejunostomy; CI: Confidence interval; OR: Odds ratio.

Table 6 Multivariate analysis of risk factors for early, Clavien-Dindo classification ≥ 3, and esophagojejunostomy-related complications

Variables	Early complications		CDC ≥ 3 complications		EJ related complications
	OR (95%CI)	P value	OR (95%CI)	P value	OR (95%CI)	P value
Type of surgery
TLTG	1		1		1
OTG	1.275 (0.719-2.262)	0.405	1.431 (0.650-3.153)	0.373	3.546 (0.908-13.854)	0.069
Age
< 60			1		1
≥ 60			2.391 (1.013-5.641)	0.047	9.925 (1.245-79.107)	0.030
BMI
< 25	1
≥ 25	1.824 (1.029-3.234)	0.040
ASA score
1-2	1
3	3.154 (1.084-9.174)	0.035

Values are expressed as mean ± SD or n (%). TLTG: Totally laparoscopic total gastrectomy; OTG: Open total gastrectomy; CDC: Clavien-Dindo classification; EJ: Esophagojejunostom; CI: Confidence interval; OR: Odds ratio; BMI: Body mass index; ASA score: American Society of Anesthesiologists Physical Status Classification.