Complications Following Open Versus Minimally Invasive Resection of Gastric Adenocarcinoma
ABSTRACT
Background and Objectives
Gastric adenocarcinoma (GA) is commonly treated with open or minimally invasive surgery (MIS). The preferred surgical approach remains unclear. This study sought to assess utilization over time, compare complication rates by surgical approach, and identify predictors of experiencing complications.
Methods
Patients who underwent GA resection from 2016 to 2022 were identified in the American College of Surgeons National Surgical Quality Improvement Program and compared based on receipt of open gastrectomy versus MIS. Complication rates were compared with χ2 tests. Predictors of experiencing complications or receiving MIS were assessed using multivariable Poisson regressions with robust variance.
Results
Out of 4,429 patients, most underwent open gastrectomy versus MIS (84.2% vs. 15.9%). MIS uptake did not increase. Open gastrectomy patients experienced more major complications (18.5% vs. 13.1%), higher perioperative mortality (1.53% vs. 0.57%), and longer hospital stays (7 vs. 5 days) compared to MIS patients (all p values < 0.01). MIS patients had a decreased risk of experiencing any complications (RR: 0.7, 95% CI: 0.5–0.8). Non-white patients were less likely to receive MIS.
Conclusions
MIS is associated with a decreased risk of experiencing complications compared to open gastrectomy for GA, yet its utilization has plateaued. Sociodemographic predictors of receipt of MIS indicate potential disparities in accessing certain treatments.
Summary
-
The preferred surgical approach for gastric cancer is unclear. This analysis of the American College of Surgeons National Surgical Quality Improvement Program compared complication rates of open gastrectomy with minimally invasive surgery (MIS).
-
MIS was associated with a decreased risk of experiencing complications, yet utilization has plateaued.
Abbreviations
-
- ACS
-
- American College of Surgeons
-
- ASA
-
- American Society of Anesthesiologists
-
- CI
-
- Confidence interval
-
- CPT
-
- Current Procedural Terminology
-
- GA
-
- Gastric adenocarcinoma
-
- ICD
-
- International Classification of Diseases
-
- MIS
-
- Minimally invasive surgery
-
- NSQIP
-
- National Surgical Quality Improvement Program
-
- OR
-
- Operating room
-
- RR
-
- Relative risk
1 Introduction
Gastric adenocarcinoma (GA) is one of the most common types of cancer and the third leading cause of cancer-related death worldwide [1]. Traditionally, anatomic gastrectomy for GA necessitated an open approach. However, advances in minimally invasive surgery (MIS) have made laparoscopic or robotic resection for GA increasingly feasible [2]. Consequentially, MIS gastrectomy has become increasingly prevalent in clinical practice as an alternative surgical approach to the traditionally utilized open gastrectomy.
It remains unclear whether there are any notable benefits to MIS gastrectomy over open gastrectomy since the open approach may be selected for patients with more advanced tumors or more urgent symptoms. Numerous studies report that both MIS gastrectomy and open gastrectomy exhibit similar morbidity, perioperative mortality, long-term survival, and oncologic quality [3-10]. However, the literature also supports that MIS gastrectomy may be associated with advantages compared to open gastrectomy, including fewer complications, increased pain tolerance, and shortened recovery time [11-28]. Given these varied results, further studies are needed to evaluate and compare the effectiveness of MIS versus open gastrectomy to identify a preferred surgical approach for GA resection.
Since postoperative benefits for MIS gastrectomy compared to open gastrectomy need to be further defined, this study intends to contribute to the current discussions attempting to identify the optimal surgical approach for GA resection. The objectives of this study are to (1) compare rates of postoperative complications by surgical approach, (2) identify the relative risk of experiencing postoperative complications by surgical approach, (3) identify predictors of MIS gastrectomy compared to open gastrectomy, and (4) compare rates of receipt of MIS gastrectomy over time.
2 Materials and Methods
2.1 Study Design and Data Source
This study is a retrospective observational cohort analysis of patients diagnosed with GA who underwent surgical resection from 2016 to 2022 from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) participant use files. The ACS NSQIP database includes clinical and laboratory data from nearly 700 participating hospitals to examine outcomes associated with improved quality of surgical services and patient satisfaction. NSQIP is a validated and prospectively maintained surgical registry. Nurse abstractors are trained to collect over 150 variables from patient records including demographics, preoperative comorbidities, operative characteristics, and postoperative events. The accuracy and reliability of data collection are ensured through periodic auditing of participating hospitals [29]. The Northwestern University Institutional Review Board deemed this study exempt from review as the data were de-identified.
2.2 Participants
Patients with a diagnosis of GA with a known treatment strategy who underwent either open or MIS resection with general surgery or thoracic surgery services were included in the analysis. Patients were identified as having GA based on International Classification of Diseases (ICD) codes. Patients with the ICD-9 codes 151.0–151.9 or the ICD-10 codes C16–C16.9 were included. Patients with disseminated cancer and patients requiring emergent surgery were excluded. Patients who did not have a major complication but withdrew from care or expired were also excluded from the analysis, as it was presumed that these individuals may have received palliative MIS procedures of the stomach as opposed to primary tumor resection.
2.3 Surgical Approach
Patients were categorized depending on whether they received an open gastrectomy or MIS gastrectomy for surgical resection of GA. Comparison groups were determined by utilizing Current Procedural Terminology (CPT) codes. The CPT codes 43620 (Gastrectomy, total; with esophagoenterostomy), 43621 (Gastrectomy, total; with Roux-en-Y reconstruction), 43622 (Gastrectomy, total; with formation of an intestinal pouch, any type), 43631 (Gastrectomy, partial, distal; with gastroduodenostomy), 43632 (Gastrectomy, partial, distal; with gastrojejunostomy), 43633 (Gastrectomy, partial, distal; with Roux-en-Y reconstruction), and 43634 (Gastrectomy, partial, distal; with formation of intestinal pouch) were used to represent the open gastrectomy group, and the CPT code 43659 (Laparoscopic procedure on the stomach) was used to represent the MIS gastrectomy group.
2.4 Patient Demographic and Clinical Characteristic Variables
Demographic and clinical characteristic variables were analyzed, such as sex, race/ethnicity, immunosuppressive therapy, and malnourishment. Immunosuppressive therapy was defined as steroid or immunosuppressant use for a chronic condition. Baseline comorbidities such as diabetes mellitus, hypertension, and smoking status were also analyzed.
2.5 Outcomes
The primary outcome of interest was all-cause complication rate and major complication rate. The secondary outcome of interest was surgical approach. To assess for rates of specific complications, multiple binary outcome variables, such as superficial incisional surgical site infection, return to operating room (OR), and sepsis or septic shock, were utilized. Patients were considered to have a major complication, as defined by NSQIP, if they experienced any of the following: cardiac arrest requiring cardiopulmonary resuscitation, myocardial infarction, pneumonia, progressive renal insufficiency, acute renal failure, pulmonary embolism/venous thromboembolism, return to the OR, deep incisional/organ space surgical site infection, sepsis or septic shock, wound disruption, urinary tract infection, or unplanned intubation [30]. Patients were considered to have any complication if they experienced any of the major complications or any of the following: open wound/wound infection, superficial incisional surgical site infection, stroke, blood transfusion, or Clostridioides difficile infection.
2.6 Statistical Analysis
Descriptive statistics were calculated for the final cohort of patients. Bivariate comparisons for continuous variables were assessed using t-tests, and categorical variables were assessed with χ2 tests. Multivariable Poisson regression with robust variance models was used to determine the relative risk (RR) of receiving a major complication, any complication, or MIS gastrectomy compared to open gastrectomy [31]. Variables were included in these models based on forward stepwise selection, and additional covariates were added based on clinical and literature-reported relevance [32]. These variables consisted of age, sex assigned at birth, and race/ethnicity. A 3:1 propensity match was performed for each regression based on patients' comorbidities, including history of diabetes mellitus, history of smoking, functional health status, history of chronic obstructive pulmonary disease, history of hypertension requiring medication, and body mass index. For each of the models, 1564 patients were included, and 95% confidence intervals (CIs) and p values were calculated for all RRs. Rates of receipt of MIS gastrectomy by year were compared using a Cochran–Armitage test for trend. p values were derived using two-tailed tests, and a value of < 0.05 was considered statistically significant. Patients with incomplete or missing covariates were dropped from the regression analysis. All analyzes were conducted using Stata SE 16.1 (College Station, Texas).
3 Results
3.1 Patient Demographics and Comorbidities
The final cohort for analysis following inclusion and exclusion criteria included 4429 patients. The patients were predominantly male (58.3% [2584/4429]) and non-Hispanic white (37.0% [1631/4429]) and had American Society of Anesthesiologists (ASA) classification 3 (68.6% [3038/4429]). Most patients underwent open gastrectomy (84.2% [3727/4429]), whereas 702/4429 (15.9%) of patients received MIS gastrectomy. Notably, more individuals in the open gastrectomy group were male (59.4% [2214/3727] vs. 52.7% [370/702]), non-Hispanic black (13.9% [517/3727]) vs. 8.1% [57/702]), and malnourished (6.5% [243/3727] vs. 3.4% [24/702]) and had ASA classification 3 (69.5% [2590/3727] vs. 63.8% [448/702] [Table 1; Table 2]).
Demographic | Surgical approach | Total | |
---|---|---|---|
Open | MIS | ||
Total, N (%) | 3727 (84.15) | 702 (15.85) | 4429 (100.00) |
Sex, N (%) | |||
Male | 2214 (59.40) | 370 (52.71) | 2584 (58.34) |
Female | 1523 (40.60) | 332 (47.29) | 1845 (41.66) |
Race/Ethnicity, N (%) | |||
Non-Hispanic white | 1352 (36.46) | 279 (39.80) | 1631 (36.99) |
Non-Hispanic black | 517 (13.94) | 57 (8.13) | 574 (13.02) |
Asian | 581 (15.67) | 85 (12.13) | 666 (15.11) |
Hispanic | 330 (8.90) | 61 (8.70) | 391 (8.87) |
Other/Unknown | 928 (25.03) | 219 (31.24) | 1147 (26.01) |
Age quartile, N (%) | |||
18–58 | 941 (25.25) | 161 (22.93) | 1102 (24.88) |
59–67 | 911 (24.44) | 151 (21.51) | 1062 (23.98) |
68–75 | 918 (24.63) | 175 (24.93) | 1093 (24.68) |
76–90+ | 957 (25.68) | 215 (30.63) | 1172 (26.46) |
Immunosuppressive therapya, N (%) | |||
Yes | 175 (4.70) | 36 (5.13) | 211 (4.76) |
No | 3552 (95.30) | 666 (94.87) | 4218 (95.24) |
Malnourishment, N (%) | |||
Yes | 243 (6.52) | 24 (3.42) | 267 (6.03) |
No | 2488 (66.76) | 451 (64.25) | 2939 (66.36) |
Unknown | 996 (26.72) | 227 (32.34) | 1223 (27.61) |
Bleeding disorders, N (%) | |||
Yes | 132 (3.54) | 20 (2.85) | 152 (3.43) |
No | 3595 (96.46) | 682 (97.15) | 4277 (96.57) |
ASA classification, N (%) | |||
1—No disturbance | 27 (0.72) | 5 (0.71) | 32 (0.72) |
2—Mild disturbance | 848 (22.75) | 194 (27.64) | 1042 (23.53) |
3—Severe disturbance | 2590 (69.49) | 448 (63.82) | 3038 (68.59) |
4—Life threat | 257 (6.90) | 54 (7.69) | 311 (7.02) |
Total operation time (min), median (IQR) | 235 (177–310) | 262 (171–366) | 239 (176–319) |
Location within stomachb, N (%) | |||
Cardia or fundus | 396 (10.63) | 79 (11.25) | 475 (10.72) |
Lesser curvature | 131 (3.51) | 32 (4.56) | 163 (3.68) |
Body or greater curvature | 496 (13.31) | 105 (14.96) | 601 (13.57) |
Pylorus or antrum | 732 (19.64) | 115 (16.38) | 847 (19.12) |
Overlapping sites | 195 (5.23) | 40 (5.70) | 235 (5.31) |
Unspecified or unknown | 1777 (47.68) | 331 (47.15) | 2108 (47.60) |
- Abbreviations: ASA, American Society of Anesthesiologists; IQR, interquartile range; MIS, minimally invasive surgery; N, number.
- a Can include steroids or immunosuppressants for a chronic condition.
- b As termed by ICD-9 and ICD-10 codes.
Comorbidity | Surgical approach | Total | p value | |
---|---|---|---|---|
Open | MIS | |||
Diabetes mellitus with oral agents or insulin, N (%) | ||||
Insulin | 234 (6.28) | 41 (5.84) | 275 (6.21) | 0.77 |
Non-insulin | 565 (15.16) | 101 (14.39) | 666 (15.04) | |
No diabetes | 2928 (78.56) | 560 (79.77) | 3488 (78.75) | |
Current smoker within 1 year, N (%) | ||||
Yes | 664 (17.82) | 91 (12.96) | 755 (17.05) | < 0.01 |
No | 3063 (82.18) | 611 (87.04) | 3674 (82.95) | |
Functional health status before surgery, N (%) | ||||
Independent | 3649 (97.91) | 683 (97.29) | 4332 (97.81) | 0.06 |
Partially dependent | 64 (1.72) | 14 (1.99) | 78 (1.76) | |
Totally dependent | 7 (0.19) | 0 (0.00) | 7 (0.16) | |
Unknown | 7 (0.19) | 5 (0.71) | 12 (0.27) | |
History of severe chronic obstructive pulmonary disease, N (%) | ||||
Yes | 192 (5.15) | 32 (4.56) | 224 (5.06) | 0.51 |
No | 3535 (94.85) | 670 (95.44) | 4205 (94.94) | |
Hypertension requiring medication, N (%) | ||||
Yes | 1955 (52.46) | 377 (53.70) | 2332 (52.65) | 0.54 |
No | 1772 (47.54) | 325 (46.30) | 2097 (47.35) | |
Body mass index, median (IQR) | 26.21 (23.08–30.04) | 26.15 (23.08–29.99) | 26.21 (23.08–30.04) | 0.49 |
- Abbreviations: IQR, interquartile range; MIS, minimally invasive surgery; N, number.
3.2 Outcomes
A greater percentage of patients in the open gastrectomy group experienced a major postoperative complication (18.5% [691/3727] vs. 13.1% [92/702], p < 0.01) or any complication (32.6% [1213/3727] vs. 21.8% [153/702], p < 0.01) compared to patients in the MIS gastrectomy group. Specifically, more patients who underwent open gastrectomy compared to MIS gastrectomy experienced a deep incisional or organ space infection (7.2% [268/3727] vs. 4.1% [29/702], p < 0.01), blood transfusion (10.1% [378/3727] vs. 5.6% [39/702], p < 0.01), pneumonia (5.3% [196/3727] vs. 2.9% [20/702], p < 0.01), unplanned intubation (3.0% [111/3727] vs. 1.4% [10/702], p = 0.02), cardiac arrest requiring cardiopulmonary resuscitation (1.0% [37/3727] vs. 0.1% [1/702], p = 0.03), and sepsis or septic shock (5.9% [221/3727] vs. 3.6% [25/702], p = 0.01). The MIS gastrectomy group had more patients who were discharged home (94.4% [663/3727] vs. 90.1% [3356/3727], p < 0.01), a decreased rate of perioperative mortality (0.6% [4/702] vs. 1.5% [57/3727], p < 0.01), and a shorter median length of total hospital stay (5 days vs. 7 days, p < 0.01) compared to the open gastrectomy group (Table 3). The MIS gastrectomy group had a longer median total operation time (262 min vs. 235 min) compared to the open gastrectomy group (Table 1).
Outcome | Surgical approach | Total | p value | |
---|---|---|---|---|
Open | MIS | |||
Superficial incisional surgical site infection, N (%) | ||||
Yes | 136 (3.65) | 17 (2.42) | 153 (3.45) | 0.10 |
No | 3591 (96.35) | 685 (97.58) | 4276 (96.55) | |
Deep incisional/organ space surgical site infection, N (%) | ||||
Yes | 268 (7.19) | 29 (4.13) | 297 (6.71) | < 0.01 |
No | 3459 (92.81) | 673 (95.87) | 4132 (93.29) | |
Urinary tract infection, N (%) | ||||
Yes | 62 (1.66) | 15 (2.14) | 77 (1.74) | 0.38 |
No | 3665 (98.34) | 687 (97.86) | 4352 (98.26) | |
Blood transfusion, N (%) | ||||
Yes | 378 (10.14) | 39 (5.56) | 417 (9.42) | < 0.01 |
No | 3349 (89.86) | 663 (94.44) | 4012 (90.58) | |
Return to OR, N (%) | ||||
Yes | 246 (6.60) | 39 (5.56) | 285 (6.43) | 0.30 |
No | 3481 (93.40) | 663 (94.44) | 4144 (93.57) | |
Pulmonary embolism/Venous thromboembolism, N (%) | ||||
Yes | 74 (1.99) | 11 (1.57) | 85 (1.92) | 0.46 |
No | 3653 (98.01) | 691 (98.43) | 4344 (98.08) | |
Acute renal failure, N (%) | ||||
Yes | 19 (0.51) | 1 (0.14) | 20 (0.45) | 0.31 |
Postop dialysis | 3 (0.08) | 0 (0.00) | 3 (0.07) | |
No | 3705 (99.41) | 701 (99.86) | 4406 (99.48) | |
Pneumonia, N (%) | ||||
Yes | 196 (5.26) | 20 (2.85) | 216 (4.88) | < 0.01 |
No | 3531 (94.74) | 682 (97.15) | 4213 (95.12) | |
Unplanned intubation, N (%) | ||||
Yes | 111 (2.98) | 10 (1.42) | 121 (2.73) | 0.02 |
No | 3616 (97.02) | 692 (98.58) | 4308 (97.27) | |
Cardiac arrest requiring cardiopulmonary resuscitation, N (%) | ||||
Yes | 37 (0.99) | 1 (0.14) | 38 (0.86) | 0.03 |
No | 3690 (99.01) | 701 (99.86) | 4391 (99.14) | |
Sepsis or septic shock, N (%) | ||||
Yes | 221 (5.93) | 25 (3.56) | 246 (5.55) | 0.01 |
No | 3506 (94.07) | 677 (96.44) | 4183 (94.45) | |
Major complication, N (%) | ||||
Yes | 691 (18.54) | 92 (13.11) | 783 (17.68) | < 0.01 |
No | 3036 (81.46) | 610 (86.89) | 3646 (82.32) | |
Any complication, N (%) | ||||
Yes | 1213 (32.55) | 153 (21.79) | 1366 (30.84) | < 0.01 |
No | 2514 (67.45) | 549 (78.21) | 3063 (69.16) | |
Length of total hospital stay (days), median (IQR) | 7 (5–9) | 5 (3–7) | 7 (5–9) | < 0.01 |
Length of total hospital stay (days), mean (SD) | 8.48 (5.94) | 6.16 (5.37) | 8.11 (5.91) | |
Discharge destination, N (%) | ||||
Home | 3356 (90.05) | 663 (94.44) | 4019 (90.74) | < 0.01 |
Rehab or facility that was not home | 249 (6.68) | 29 (4.13) | 278 (6.28) | |
Perioperative mortality | 57 (1.53) | 4 (0.57) | 61 (1.38) | |
Unknown | 65 (1.74) | 6 (0.85) | 71 (1.60) | |
Unplanned readmission 1, N (%) | ||||
Yes | 419 (11.24) | 58 (8.26) | 477 (10.77) | 0.06 |
No | 3 (0.08) | 1 (0.14) | 4 (0.09) | |
Unknown | 3305 (88.68) | 643 (91.60) | 3948 (89.14) |
- Abbreviations: IQR, interquartile range; MIS, minimally invasive surgery; N, number; OR, operating room; SD, standard deviation.
3.3 Relative Risk of Experiencing a Major Complication
On multivariable Poisson regression with robust variance, patients who underwent MIS gastrectomy had a decreased risk of experiencing a major complication compared to patients receiving open gastrectomy (RR: 0.7, 95% CI: 0.5–0.9). Furthermore, patients who were non-Hispanic black (RR: 0.6, 95% CI: 0.4–0.9) or Asian (RR: 0.6, 95% CI: 0.4–0.8) had a decreased risk of experiencing a major complication compared to non-Hispanic white patients (Table 4).
Relative risk | 95% Confidence interval | p value | ||
---|---|---|---|---|
Surgical approach | ||||
Open | 1 | Reference | ||
MIS | 0.66 | 0.51–0.86 | < 0.01 | |
Age | 0.97 | 0.97–0.98 | < 0.01 | |
Sex | ||||
Male | 1 | Reference | ||
Female | 0.87 | 0.70–1.07 | 0.18 | |
Race/Ethnicity | ||||
Non-Hispanic white | 1 | Reference | ||
Non-Hispanic black | 0.59 | 0.41–0.85 | < 0.01 | |
Asian | 0.57 | 0.40–0.82 | < 0.01 | |
Hispanic | 0.76 | 0.52–1.10 | 0.15 | |
Other/Unknown | 0.76 | 0.58–0.98 | 0.03 | |
Diabetes mellitus with oral agents or insulin | ||||
No | 1 | Reference | ||
Yes | 1.21 | 0.93–1.58 | 0.16 | |
Current smoker within 1 year | ||||
No | 1 | Reference | ||
Yes | 1.13 | 0.84–1.50 | 0.43 | |
ASA classification | ||||
2—Mild disturbance | 1 | Reference | ||
3—Severe disturbance | 1.17 | 0.92–1.49 | 0.21 | |
4—Life threat | 1.4 | 0.88–2.23 | 0.16 | |
None assigned | 0.00 | 0.00–0.00 | < 0.01 | |
Malnourishment | ||||
No | 1 | Reference | ||
Yes | 1.22 | 0.96–1.59 | 0.27 | |
Hypertension requiring medication | ||||
No | 1 | Reference | ||
Yes | 1.24 | 0.96–1.59 | 0.10 | |
History of severe chronic obstructive pulmonary disease | ||||
No | 1 | Reference | ||
Yes | 0.85 | 0.50–1.45 | 0.56 |
- Abbreviations: ASA, American Society of Anesthesiologists; MIS, minimally invasive surgery.
3.4 Relative Risk of Experiencing Any Complication
On multivariable Poisson regression with robust variance, patients who underwent MIS gastrectomy had a decreased risk of experiencing any complication (RR: 0.7, 95% CI: 0.5–0.8) compared to patients who underwent open gastrectomy (Table 5).
Relative risk | 95% Confidence interval | p value | ||
---|---|---|---|---|
Surgical approach | ||||
Open | 1 | Reference | ||
MIS | 0.65 | 0.53–0.78 | < 0.01 | |
Age | 0.98 | 0.98–0.99 | < 0.01 | |
Sex | ||||
Male | 1 | Reference | ||
Female | 0.89 | 0.76–1.03 | 0.11 | |
Race/Ethnicity | ||||
Non-Hispanic white | 1 | Reference | ||
Non-Hispanic black | 0.71 | 0.55–0.91 | 0.01 | |
Asian | 0.56 | 0.42–0.73 | < 0.01 | |
Hispanic | 0.85 | 0.66–1.11 | 0.24 | |
Other/Unknown | 0.91 | 0.76–1.09 | 0.28 | |
Diabetes mellitus with oral agents or insulin | ||||
No | 1 | Reference | ||
Yes | 1.10 | 0.90–1.33 | 0.34 | |
Current smoker within 1 year | ||||
No | 1 | Reference | ||
Yes | 0.97 | 0.78–1.21 | 0.80 | |
ASA classification | ||||
2—Mild disturbance | 1 | Reference | ||
3—Severe disturbance | 1.19 | 0.99–1.43 | 0.06 | |
4—Life threat | 1.26 | 0.90–1.78 | 0.18 | |
None assigned | 0.00 | 0.00–0.00 | < 0.01 | |
Malnourishment | ||||
No | 1 | Reference | ||
Yes | 1.21 | 0.94–1.54 | 0.14 | |
Hypertension requiring medication | ||||
No | 1 | Reference | ||
Yes | 1.09 | 0.91–1.30 | 0.35 | |
History of severe chronic obstructive pulmonary disease | ||||
No | 1 | Reference | ||
Yes | 1.02 | 0.71–1.46 | 0.90 |
- Abbreviations: ASA, American Society of Anesthesiologists; MIS, minimally invasive surgery.
3.5 Predictors and Rates of Receipt of MIS Gastrectomy
On multivariable Poisson regression with robust variance, patients who were non-Hispanic black (RR: 0.6, 95% CI: 0.4–0.8), Asian (RR: 0.7, 95% CI: 0.5–0.9), or Hispanic (RR: 0.7, 95% CI: 0.5–0.9) were less likely to receive MIS gastrectomy compared to non-Hispanic white patients. Likewise, patients with ASA classification 3 compared to ASA classification 2 (RR: 0.7, 95% CI: 0.6–0.9) and patients who were malnourished compared to patients who were not malnourished (RR: 0.6, 95% CI: 0.4–0.9) were also less likely to receive MIS gastrectomy (Table 6). On the Cochran–Armitage test for trend, rates of receipt of MIS gastrectomy did not vary significantly over time, though the rates did fluctuate by year, with there being the least amount of MIS gastrectomy performed in 2018 (9.9% [59/595]) and the most performed in 2021 (20.5% [123/599]; Table 7).
Relative risk | 95% Confidence interval | p value | ||
---|---|---|---|---|
Age | 0.99 | 0.98–0.99 | < 0.01 | |
Sex | ||||
Male | 1 | Reference | ||
Female | 1.07 | 0.93–1.23 | 0.34 | |
Race/Ethnicity | ||||
Non-Hispanic white | 1 | Reference | ||
Non-Hispanic black | 0.56 | 0.42–0.75 | < 0.01 | |
Asian | 0.68 | 0.53–0.86 | < 0.01 | |
Hispanic | 0.65 | 0.48–0.88 | 0.01 | |
Other/Unknown | 0.91 | 0.77–1.08 | 0.28 | |
Diabetes mellitus with oral agents or insulin | ||||
No | 1 | Reference | ||
Yes | 1.04 | 0.86–1.27 | 0.67 | |
Current smoker within 1 year | ||||
No | 1 | Reference | ||
Yes | 0.94 | 0.75–1.17 | 0.57 | |
ASA classification | ||||
2—Mild disturbance | 1 | Reference | ||
3—Severe disturbance | 0.72 | 0.62–0.85 | < 0.01 | |
4—Life threat | 0.99 | 0.75–1.32 | 0.97 | |
None assigned | 0.96 | 0.26–3.56 | 0.95 | |
Malnourishment | ||||
No | 1 | Reference | ||
Yes | 0.62 | 0.43–0.89 | 0.01 | |
Hypertension requiring medication | ||||
No | 1 | Reference | ||
Yes | 1.09 | 0.92–1.29 | 0.34 | |
History of severe chronic obstructive pulmonary disease | ||||
No | 1 | Reference | ||
Yes | 1.09 | 0.77–1.55 | 0.64 |
- Abbreviation: ASA, American Society of Anesthesiologists.
Year | Surgical approach | Total | p value | |
---|---|---|---|---|
Open | MIS | |||
2016, N (%) | 551 (81.39) | 126 (18.61) | 677 (100.00) | 0.18 |
2017, N (%) | 556 (85.94) | 91 (14.06) | 647 (100.00) | |
2018, N (%) | 536 (90.08) | 59 (9.92) | 595 (100.00) | |
2019, N (%) | 539 (83.57) | 106 (16.43) | 645 (100.00) | |
2020, N (%) | 549 (85.51) | 93 (14.49) | 642 (100.00) | |
2021, N (%) | 476 (79.47) | 123 (20.53) | 599 (100.00) | |
2022, N (%) | 520 (83.33) | 104 (16.67) | 624 (100.00) |
- Abbreviations: MIS, minimally invasive surgery; N, number.
4 Discussion
The results of this study show that MIS gastrectomy compared to open gastrectomy is associated with improved postoperative outcomes for patients undergoing surgical resection of GA. Notably, patients receiving MIS gastrectomy have a lower risk of experiencing any complication, including major complications, compared to patients receiving open gastrectomy. However, predictors of receipt of MIS gastrectomy over open gastrectomy indicate that there may be sociodemographic disparities in regard to access to certain surgical approaches.
Though there are studies that indicate that outcomes are similar for MIS gastrectomy and open gastrectomy, the results of this study support the majority of the literature, which states that MIS gastrectomy compared to open gastrectomy is associated with numerous postoperative benefits, including reduced complication rates. Notably, many of the studies that did not identify any differences in postoperative outcomes by surgical approach specifically focused on long-term outcomes, including 90-day mortality and overall survival, or oncologic outcomes, such as the number of harvested lymph nodes and tumor localization [6-10]. Though MIS gastrectomy and open gastrectomy may have comparable long-term outcomes and oncologic effectiveness, the potential short-term benefits for patients undergoing MIS gastrectomy, including lower postoperative complication rates, decreased operative blood loss, and reduced recovery time, should be taken into consideration when determining which surgical approach to utilize for GA resection [12, 13, 15-22, 24-27]. For instance, a recent retrospective cohort study comparing the effectiveness of open versus laparoscopic gastrectomy for resection of Siewert II/III adenocarcinoma demonstrated this reduced recovery time for patients in the laparoscopic group. Specifically, these patients experienced shorter times to first flatus, liquid diet, and first ambulation, highlighting a potential short-term benefit of MIS [27].
Based on the identified predictors of receipt of MIS gastrectomy compared to open gastrectomy, it is important to recognize that there may be sociodemographic disparities related to accessing certain treatment modalities. Specifically, non-Hispanic black patients, Asian patients, and Hispanic patients were more likely to receive open gastrectomy compared to non-Hispanic white patients. We see this difference in access, and while the complication rates in these groups were minimal, we urge further research into this area to ensure that there is no sociodemographic disparity in postsurgical outcomes that is missed by the limitations of this study.
In addition to the postoperative benefits that patients undergoing MIS gastrectomy for GA resection may experience, there are other considerations with MIS surgery that are important to note. For instance, MIS gastrectomy requires few small incisions compared to the much longer incision required to open the abdomen during open gastrectomy. Not only does this result in a cosmetically favorable outcome with minimal scarring, but this minimally invasive approach tends to be associated with decreased patient anxiety as well [17, 22]. Furthermore, multiple studies have shown that MIS gastrectomy is associated with improved postoperative pain compared to open gastrectomy. While the Laparoscopic Versus Open Gastrectomy for Gastric Cancer randomized controlled trial demonstrated comparable postoperative pain scores for both MIS and open gastrectomy, more patients in the open group received epidurals and consumed more opioids compared to patients in the MIS group [14]. Likewise, additional studies have demonstrated similar results, with patients undergoing MIS gastrectomy compared to open gastrectomy experiencing less postoperative pain [22, 24]. Therefore, surgeons should consider these potential benefits to the patient's postoperative experience when selecting a surgical approach for GA resection.
There are several limitations associated with this study. For instance, it is important to consider the validity of the codes used to categorize the MIS versus open gastrectomy comparison groups. Though there were clear CPT codes to distinguish the various types of open gastrectomy approaches, the only CPT code pertaining to MIS gastrectomy was the code 43659, which is defined as a laparoscopic procedure on the stomach. Given the vague nature of this CPT code, it is impossible to determine the composition of laparoscopic procedures included in this classification. Though it is likely that the vast majority of the procedures encapsulated by this code are indeed laparoscopic gastrectomy procedures, it is possible that this code includes palliative laparoscopic procedures of the stomach that do not pertain to primary tumor resection. To account for this, patients who did not have a major complication but withdrew from care or expired were excluded from the final cohort. In addition, since data from the ACS NSQIP are only collected from participating hospitals, there is sampling bias associated with which hospitals and patient populations are included in the analysis. This may underscore disparities observed in predictors of surgical approach for marginalized groups, as these groups are often underrepresented in the NSQIP. Finally, the NSQIP database lacks data for the demographic and clinical characteristics of some patients, limiting our ability to draw certain conclusions. For example, there is a considerable proportion of patients who lack data pertaining to racial and ethnic identity, making it difficult to determine the true role of racial and ethnic identity as a predictor of receipt of MIS gastrectomy. Likewise, almost half of all patients in this study had an unspecified or unknown tumor location. Given that tumor location tends to impact surgeons' resection approaches, this lack of data restricts our ability to determine whether tumor location is a predictor of receipt of MIS surgery. Similarly, without information on cancer staging or symptomatology, there may remain signification confounding by indication for patients selected to undergo one approach versus the other.
5 Conclusions
MIS gastrectomy was independently predictive of lower complication rates compared to open gastrectomy for resection of GA. Sociodemographic predictors of receipt of MIS gastrectomy compared to open gastrectomy indicate that there may be disparities regarding who has access to certain treatments and surgical approaches. Surgeons should consider MIS resection for any eligible patients to minimize complications and improve postoperative outcomes.
Acknowledgments
Dominic J. Vitello was supported by NIH grant number 5R38CA245095.
Conflicts of Interest
The authors declare no conflicts of interest.
Open Research
Data Availability Statement
Data sharing is not applicable to this article as no new data were created or analyzed in this study.
References
Synopsis
The preferred surgical approach for gastric cancer is unclear. This analysis of the American College of Surgeons National Surgical Quality Improvement Program compared complication rates of open gastrectomy versus minimally invasive surgery (MIS). MIS was associated with decreased risk of experiencing complications, yet utilization has plateaued.