Comparing the Effectiveness of Open, Laparoscopic, and Robotic Gastrectomy in the United States: A Retrospective Analysis of Perioperative, Oncologic, and Survival Outcomes

Abstract

Introduction: Minimally invasive surgery (MIS) is increasingly used in the surgical management of gastric cancer; however, its adoption lags that of other cancers. Most randomized controlled trials comparing MIS to open gastrectomy have been conducted in Asia, with limited data from the United States. This study aimed to compare perioperative, oncologic, and survival outcomes between open, laparoscopic, and robotic gastrectomy in a large US cohort.

Methods: Using the National Cancer Database, we identified patients with gastric adenocarcinoma who underwent open, laparoscopic, or robotic gastrectomy between 2010 and 2020. Multivariate regression models were used to examine the association between surgical approach and various outcomes, including 30-d readmission, length of stay (LOS), surgical margin status, lymph node yield, 30- and 90-d mortality, and overall survival (OS). The interaction between surgical approach and tumor location (distal versus proximal or gastroesophageal junction [GEJ]) was also assessed.

Results: Of the 34,937 included patients, 64.8% underwent open gastrectomy, 25.7% underwent laparoscopic surgery, and 9.5% underwent robotic surgery. MIS was associated with lower odds of 30-d readmission (laparoscopic: odds ratio [OR] 0.78, 95% confidence interval [CI] 0.67-0.89; robotic: OR 0.75, 95% CI 0.60-0.92), positive margins (laparoscopic: OR 0.83, 95% CI 0.74-0.93; robotic: OR 0.75, 95% CI 0.62-0.90), 30-d mortality (laparoscopic: OR 0.69, 95% CI 0.55-0.85; robotic: OR 0.66, 95% CI 0.44-0.95), and 90-d mortality (laparoscopic: OR 0.74, 95% CI 0.63-0.87; robotic: OR 0.63, 95% CI 0.47-0.84), as well as improved OS (laparoscopic: hazard ratio 0.83, 95% CI 0.79-0.87; robotic: hazard ratio 0.76, 95% CI 0.69-0.83) compared to open surgery. Considering the interaction of approach with tumor location, for proximal/GEJ tumors, the associated outcome improvements with MIS were attenuated. We observe that the odds for 30-d readmission, 90-d mortality, and OS are similar to those for open operations. However, regardless of tumor location, robotic gastrectomy was associated with decreased LOS and yielded a higher lymph node count than laparoscopic or open approaches.

Conclusions: In this large US cohort, MIS gastrectomy was associated with improved perioperative, oncologic, and survival outcomes compared to open surgery for distal gastric cancers. However, the associated benefits of MIS were attenuated for proximal/GEJ tumors, with higher odds of readmission, mortality, and worse OS. Notably, robotic gastrectomy was associated with superior lymph node yield and LOS compared to laparoscopic and open approaches, even for proximal/GEJ tumors. These findings underscore the need for further research, especially randomized controlled trials conducted in Western populations, to definitively determine the efficacy of MIS for distal and proximal/GEJ tumors and guide surgical decision-making for gastric adenocarcinoma.

Keywords: Gastric adenocarcinoma; Laparoscopic gastrectomy; Minimally invasive gastrectomy; Minimally invasive surgery; Open gastrectomy; Robotic gastrectomy.

Figure 1.

Patient selection flow chart.

Figure 2:

Forest plot comparing minimally invasive (laparoscopic and robotic) and open gastrectomy for 30-day readmission, positive margins, 30-day mortality, 90-day mortality, and overall survival. The plot displays odds ratios (OR) for readmission, positive margins, 30-day mortality, 90-day mortality, and hazard ratios (HR) for overall survival, along with their 95% confidence intervals (CI). The interaction terms (Approach*Prox./GEJ) represent the modifying effect of proximal/GEJ tumor location on the association between surgical approach and outcomes. This demonstrated changes in the associated outcomes when tumors were proximal or involved the gastroesophageal junction (GEJ). The red vertical dashed line at OR/HR = 1 represents the reference (open or open * proximal/GEJ).

Figure 3:

Forest plot comparing minimally invasive (laparoscopic and robotic) and open gastrectomy for length of stay (LOS), number of lymph nodes excised, and number of positive lymph nodes. The plot displays coefficients and 95% confidence intervals (CI) from linear regression models. The interaction terms (Approach*Prox./GEJ) represent the modifying effect of proximal/GEJ tumor location on the association between surgical approach and outcomes. This demonstrated changes in the associated outcomes when tumors were proximal or involved the gastroesophageal junction (GEJ). The red vertical dashed line at X = 1 represents the reference (open or open * proximal/GEJ).