Totally laparoscopic versus laparoscopy-assisted Billroth-I anastomosis for gastric cancer: a case-control and case-matched study.

objectiveTo evaluate the safety, feasibility and clinical results of the modified delta-shaped gastroduodenostomy (MDSG) in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer (GC).

methodsWe performed a case-control and case-matched study enrolling 642 patients with GC undergoing laparoscopic distal gastrectomy with Billroth-I anastomosis from January 2011 to December 2014. TLDG with MDSG was performed in 158 patients (Group TL), and laparoscopy-assisted distal gastrectomy with circular anastomosis was performed in 484 patients (Group LA). One-to-one propensity score matching (PSM) was performed to compare the clinicopathological characteristics between the two groups.

resultsPatients with smaller tumors or stage I cancer were more likely to receive TLDG (P < 0.05). In the propensity-matched analysis of 143 pairs, there were no differences in demographic and pathologic characteristics between groups (all P < 0.05). All patients successfully underwent laparoscopic radical distal gastrectomy. Before PSM, Group TL had more dissected lymph nodes (LNs), a longer time to first fluid diet and a longer postoperative length of stay than Group LA (all P < 0.05). After PSM, except for the fact that more dissected LNs were obtained in Group LA (P < 0.05), no difference was found in the intraoperative and postoperative outcomes between the groups (all P > 0.05). The postoperative complications were similar in both groups (all P > 0.05). Stratification analysis performed after PSM showed that in early GC, no difference was observed in intraoperative and postoperative outcomes between the groups (all P > 0.05). However, in locally advanced GC, Group TL had more dissected LNs and a higher rate of postoperative complications (both P < 0.05). Univariate analysis carried out in locally advanced cases after PSM showed that the body mass index (BMI), the method of digestive tract reconstruction and Charlson's score were significant factors that affected postoperative morbidity (all P < 0.05). Multivariate analysis indicated that BMI was an independent risk factor for postoperative morbidity (P < 0.05).

conclusionsThe MDSG in TLDG is safe and feasible for early GC; however, it should be chosen with caution in advanced GC, particularly in patients with a high BMI.