Laparoscopic vs Open Distal Gastrectomy for Locally Advanced Gastric Cancer: 5-Year Outcomes of the KLASS-02 Randomized Clinical Trial

Abstract

Importance: The long-term safety of laparoscopic distal gastrectomy for locally advanced gastric cancer (AGC) remains uncertain given the lack of 5-year follow-up results.

Objective: To compare the 5-year follow-up results in patients with clinically AGC enrolled in the Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS)-02 randomized clinical trial who underwent laparoscopic or open distal gastrectomy.

Design, setting, and participants: The KLASS-02, a multicenter randomized clinical trial, showed that laparoscopic surgery was noninferior to open surgery for patients with locally AGC. The present study assessed the 5-year follow-up results, including 5-year overall survival (OS) and relapse-free survival (RFS) rates and long-term complications, in patients enrolled in KLASS-02. From November 21, 2011, to April 29, 2015, patients aged 20 to 80 years diagnosed preoperatively with locally AGC were enrolled. Final follow-up was on June 15, 2021. Data were analyzed June 24 to September 9, 2021.

Interventions: Patients were treated with R0 resection either by laparoscopic gastrectomy or open gastrectomy as the full analysis set of the KLASS-02 trial.

Main outcomes and measures: Five-year OS and RFS rates, recurrence patterns, and long-term surgical complications were evaluated.

Results: This study enrolled a total of 1050 patients. A total of 974 patients were treated with R0 resection; 492 (50.5%) in the laparoscopic gastrectomy group (mean [SD] age, 59.8 [11.0] years; 351 men [71.3%]) and 482 (49.5%) in the open gastrectomy group (mean [SD] age, 59.4 [11.5] years; 335 men [69.5%]). In patients who underwent laparoscopic and open distal gastrectomy, the 5-year OS (88.9% vs 88.7%) and RFS (79.5% vs 81.1%) rates did not differ significantly. The most common types of recurrence were peritoneal carcinomatosis (73 of 173 [42.1%]), hematogenous metastases (36 of 173 [20.8%]), and locoregional recurrence (23 of 173 [13.2%]), with no between-group differences in types of recurrence at each cancer stage. The correlation between 3-year RFS and 5-year OS at the individual level was highest in patients with stage III gastric cancer (ρ = 0.720). The late complication rate was significantly lower in the laparoscopic than in the open surgery group (32 of 492 [6.5%] vs 53 of 482 [11.0%]). The most common type of complication in both groups was intestinal obstruction (13 of 492 [2.6%] vs 24 of 482 [5.0%]).

Conclusions and relevance: The 5-year outcomes of the KLASS-02 trial support the 3-year results, which is the noninferiority of laparoscopic surgery compared with open gastrectomy for locally AGC. The laparoscopic approach can be recommended in patients with locally AGC to achieve the benefit of low incidence of late complications.

Trial registration: ClinicalTrials.gov Identifier: NCT01456598.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Hyung reported receiving grants from Medtronic and GC pharma; stocks from Hutom; and personal fees from SK Hynix (Wuxi) outside the submitted work. Dr Kong reported receiving grants from Medtronic and Stryker outside the submitted work. Dr D. Park reported receiving grants from Daewoong Pharmaceuticals, JW Pharmaceuticals, and Medtronic outside the submitted work. Dr J.W. Kim reported receiving grants from DN Company Co Ltd research fund outside the submitted work. Dr Han reported receiving grants from the National R&D Program for Cancer Control and Ethicon Endo-Surgery, a Johnson & Johnson Company, during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.. Kaplan-Meier Analyses of Overall Survival After Laparoscopic Gastrectomy and Open Gastrectomy

Overall survival in all patients (A) and patients with stage I (B), stage II (C), and stage III (D) gastric cancer, based on the 8th TNM staging system (the full analysis set data set).

Figure 2.. Cumulative Incidence Rates of Patients at Risk of Late Complications Over Time After Laparoscopic Gastrectomy and Open Gastrectomy