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Adequacy of Lymph Node Resection in Open versus Minimally Invasive Surgery for Gastric Adenocarcinoma using the National Cancer Center Database
Natalie Gwilliam*1, Alexandra Kyrillos2, Ki Wan Kim2, Michael Ujiki2
1Surgery, University of Chicago, Chicago, IL; 2Surgery, NorthShore University HealthSystem, Evanston, IL
Background
Data on open gastrectomy (OG) versus minimally invasive gastrectomy (MIG) for gastric adenocarcinoma come mainly from Asia. Tumor histology and location in the West are distinct from Asian populations and current Western data on MIG are limited to single institution studies and small case series. This study uses the National Cancer Database (NCDB) for gastric cancer to examine the difference between open and MIG approaches in regards to trends in practice and adequacy of resection based on margins and lymph nodes (LN) in the US.
Methods
A retrospective analysis of the NCDB was performed on all patients undergoing surgery for gastric adenocarcinoma from 2010 to 2013. MIG included laparoscopic and robotic surgery. The study included patients who were >18 years, had no previous cancers, and had a defined surgical procedure with known approach for the primary tumor. Patients with local tumor destruction or excision via endoscopy were excluded.
Results
A total of 15,418 patients met criteria. Of these, 24% had a MIG. Over the time period, MIG increased across all stages. After multivariate analysis, MIG was less likely for African Americans, Hispanics, uninsured, community cancer programs, grade 3 cancer, clinical stages 2 or 3, and total gastrectomies (p<0.05). Academic programs and those in the Middle Atlantic or Pacific regions were more likely to have MIG. MIG achieved negative margins significantly more frequently than OG (88.5% v 81.7%, p<0.001). Inadequate LN resection (<15) was high, ranging from 29 to 69% for both the OG and MIG (Table 1). Analysis by surgical extent (partial v near-/total) and location (distal v proximal) revealed that MIG was significantly better for adequacy of LNs in partial, distal, and proximal gastrectomies (p<0.02). On multivariate analysis of gastrectectomies for stages I-III, approach was not significant for LN adequacy (p=0.059). Adequate LNs were more likely for females, grade 3 tumors, those undergoing total gastrectomy, academic centers and integrated network cancer programs, and in the Middle Atlantic and Pacific (p<0.05). Inadequate resection correlated with Medicare insurance and presence of comorbidities (p<0.05). Mean LOS was significantly shorter for MIG (10.8 v 11.5, p<0.005). Readmission within 30 days did not vary significantly (p=0.146). Disparities between approaches may reflect election of an open approach for more advanced cases or at less experienced centers.
Conclusions
Surgeons in the US are increasingly employing the MIG for gastric adenocarcinoma at all clinical stages with outcomes that are equivalent or better than open. Further subgroup analyses are needed to assess which locations and populations are most likely to benefit from an MIG approach. Of concern, both MIG and open approaches fail to resect adequate LNs in nearly 50% of cases.
 
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