Totally laparoscopic versus laparoscopy-assisted distal gastrectomy: the KLASS-07: a randomized controlled trial

Abstract

Backgrounds: Strong evidence is lacking as no confirmatory randomized controlled trials (RCTs) have compared the efficacy of totally laparoscopic distal gastrectomy (TLDG) with laparoscopy-assisted distal gastrectomy (LADG). The authors performed an RCT to confirm if TLDG is different from LADG.

Methods: The KLASS-07 trial is a multi-centre, open-label, parallel-group, phase III, RCT of 442 patients with clinical stage I gastric cancer. Patients were enroled from 21 cancer care centres in South Korea between January 2018 and September 2020 and randomized to undergo TLDG or LADG using blocked randomization with a 1:1 allocation ratio, stratified by the participating investigators. Patients were treated through R0 resections by TLDG or LADG as the full analysis set of the KLASS-07 trial. The primary endpoint was morbidity within postoperative day 30, and the secondary endpoint was quality of life (QoL) for 1 year. This trial is registered at ClinicalTrials.gov (NCT03393182).

Results: Four hundred forty-two patients were randomized (222 to TLDG, 220 to LADG), and 422 patients were included in the pure analysis (213 and 209, respectively). The overall complication rate did not differ between the two groups (TLDG vs. LADG: 12.2% vs. 17.2%). However, TLDG provided less postoperative ileus and pulmonary complications than LADG (0.9% vs. 5.7%, P= 0.006; and 0.5% vs. 4.3%, P= 0.035, respectively). The QoL was better after TLDG than after LADG regarding emotional functioning at 6 months, pain at 3 months, anxiety at 3 and 6 months, and body image at 3 and 6 months (all P< 0.05). However, these QoL differences were resolved at 1 year.

Conclusions: The KLASS-07 trial confirmed that TLDG is not different from LADG in terms of postoperative complications but has the advantages to reduce ileus and pulmonary complications. TLDG can be a good option to offer better QoL in terms of pain, body image, emotion, and anxiety at 3-6 months.

Figure 1

Flow chart of the Korean Laparoendoscopic Gastrointestinal Surgery Study 07 randomized clinical trial. LADG, laparoscopy-assisted distal gastrectomy; TLDG, totally laparoscopic distal gastrectomy.

Figure 2

Forest plot of morbidities according to patient subgroups. AJCC, American Joint Committee on Cancer; ASA, American Society of Anesthesiologists; LADG, laparoscopy-assisted distal gastrectomy; TLDG, totally laparoscopic distal gastrectomy.

Figure 3

Quality of life (QoL) measurements of the totally laparoscopic distal gastrectomy group (n=213) and laparoscopy-assisted distal gastrectomy group (n=209) using the Korean version of European Organization for Research and Treatment of Cancer questionnaire. (A) C30 emotional functioning. (B) C30 pain. (C) STO22 anxiety. (D) STO22 body image.