Short-term outcomes of distal gastrectomy versus total gastrectomy for gastric cancer under enhanced recovery after surgery: a propensity score-matched analysis

Abstract

Enhanced recovery after surgery (ERAS) has been used safely and effectively in patients with gastric cancer. Our aim was to evaluate the short-term outcomes of total gastrectomy (TG) versus distal gastrectomy (DG) for gastric cancer under ERAS. A prospectively collected database of 1349 patients with gastric cancer who underwent TG or DG between January 2016 and September 2022 was retrospectively analyzed. Propensity score matching analysis was used at a ratio of 1:1 to reduce confounding effects, and perioperative clinical outcomes were compared between the two groups. The primary outcome was overall postoperative complications (POCs). Secondary outcomes comprised time to bowel function recovery, postoperative hospital stay, mortality, and 30-day readmission rate. Of 1349 identified patients, 296 (21.9%) experienced overall POCs. Before matching, multivariable analysis revealed that age, body mass index, diabetes, operation time, and extent of gastrectomy were independent risk factors for overall POCs. After matching, each group comprised 495 patients, and no significant differences were observed between the groups for all parameters except tumor location. Compared with TG, DG was associated with significantly earlier days to first flatus and to eating a soft diet, and shorter postoperative hospital stay (P < 0.05). The incidence of overall- and severe POCs (Clavien–Dindo grade ≥ IIIa) in the TG group was significantly higher vs. the DG group (P < 0.05). There was no significant difference in the number of days to eating a liquid diet, or mortality and 30-day readmission rates between the groups (P > 0.05). In the subgroup analysis for middle-third gastric cancer, the TG group experienced higher rates of overall- and severe POCs, with a longer postoperative hospital stay. Compared with DG, patients who underwent TG had higher POC rates, slower recovery of bowel function, and longer duration of hospitalization under ERAS. Therefore, caution is needed when initiating early feeding for patients who undergo TG.

Introduction

Gastric cancer is the fifth most commonly diagnosed malignancy and the fourth leading cause of cancer deaths globally^1,2. More than 1 million people were newly diagnosed, with 0.769 million deaths, in 2020^1,2. Currently, radical gastrectomy provides a considerable survival benefit and is the most effective treatment for gastric cancer. However, the procedure is associated with major stress to the body and significant postoperative morbidity^3–5. Not surprisingly, it is important to reduce the surgical stress, which is believed to improve clinical outcomes⁶.

Enhanced Recovery After Surgery (ERAS) comprises a series of multidisciplinary evidence-based techniques for perioperative care that aim to alleviate the stress response and accelerate postoperative recovery^7,8. Several studies have demonstrated that the implementation of ERAS programs in gastrectomy can shorten the time to early ambulation, improve recovery of gut function, and reduce the length of hospital stay without increasing readmission and postoperative complications (POCs) rates^9–13. The ERAS protocol is strongly recommended for the perioperative management of gastric cancer in the sixth edition of the Japanese Gastric Cancer Treatment Guidelines¹⁴. The perioperative ERAS clinical practice guideline is similar, regardless of the extent of resection. However, compared with total gastrectomy (TG), distal gastrectomy (DG) is associated with significantly shorter operative time, less operative blood loss, faster recovery, fewer POCs, shorter hospitalization stay, and better quality of life^15–20. Hence, we investigated the differences in short-term outcomes between TG and DG for gastric cancer under ERAS.

Methods

Patients

A prospective database of gastric cancer cases from Fujian Cancer Hospital was retrospectively reviewed. From January 2016 to September 2022, 1349 patients who underwent TG or DG were enrolled in our study. The inclusion criteria were as follows: (1) age between 18 and 75 years, (2) pathologically-confirmed diagnosis of gastric adenocarcinoma, (3) elective TG or DG performed with curative intent, and (4) compliance with over 80% of the ERAS elements; lower compliance was considered ERAS pathway failure²¹. The ERAS pathway is shown in Table 1. The exclusion criteria were as follows: (1) American Society of Anesthesiologists grade IV or V, (2) emergency surgery owing to complications (bleeding, obstruction, or perforation), (3) palliative surgery, (4) multivisceral resection, (5) remnant gastric cancer, (6) insufficient clinical data for analysis, (7) conversion to open surgery, and (8) robotic gastrectomy. The study flowchart is shown in Fig. 1.

Table 1.

ERAS protocol for gastrectomy.

Time point	Protocol
Preoperative	1. Preadmission education and counseling 2. Routine nutritional screening, and significantly malnourished patients received individual nutritional support 3. No smoking or drinking, training of cardiopulmonary function if necessary 4. No preoperative mechanical bowel preparation 5. Fasting was limited to 2 h for fluid and 6 h for light meal intake Oral administration of 200 ml carbohydrate-rich solution 2 h before anesthesia
Operative	6. Prophylactic use of antibiotics 0.5–1 h before the operation and subsequently every 3 h during the surgical operation 7. Optimize the anesthetic program 8. A multimodal, opioid-sparing, pain management plan should preferably be implemented 9. Monitor body temperature and maintain it at 36–37 °C via intraoperative warming 10. Practice protective lung ventilation 11. According to surgical conditions, try to use as few abdominal drains as possible 12. Nasogastric tube should not be used whenever possible 13. Implement target-directed fluid therapy
Postoperative	Multimodal antiemetic prophylaxis is employed to reduce nausea and vomiting Start clear liquids on POD1. Gradually increase oral liquids intake on POD 2–3. Introduce a soft diet as tolerated on POD 4–6 until discharge 16. Early and progressive active ambulation from POD 1 17. Removal of urinary catheter on POD 1 18.Implement restrictive intravenous fluid administration 19. Sham feeding (chewing sugar-free gum for at least 10 min three to four times per day) 20. Provide health education before discharge

POD postoperative day.

Figure 1.

Study flowchart of patients enrolled in this study. PSM propensity score matching.

Definitions and observation indices

Tumor location was defined in accordance with the Japanese definition of three regions of the stomach (upper-third, middle-third, and lower-third)¹⁴. In cases involving multiple gastric sections, the affected portions were documented in descending order by the level of involvement, with the portion containing the majority of the tumor listed first. Pathological staging was classified in accordance with the 8th edition of the American Joint Committee on Cancer Staging System for gastric cancer^22,23. POCs were recorded and graded in accordance with the Clavien–Dindo classification, a widely validated and accepted standardized method for assessing POCs in various surgical procedures^24–26. In patients who experienced multiple complications, the stage was determined by the highest grade of POCs. All POCs were considered overall POCs (Clavien–Dindo grade I–V); grade ≥ III POCs were classified as severe POCs^18,27. Bowel function recovery was assessed as the time to the first passage of flatus and the initiation of a soft diet^28,29.

The primary outcome was POCs, with secondary outcomes of times to first flatus, first liquid intake, and first soft food intake, and nutritional markers (serum albumin and total protein) on postoperative day 7, postoperative hospital stay, and mortality and 30-day readmission rates.

Statistical analysis

Data analyses were performed using SPSS 24.0 statistical software. All figures were created using GraphPad Prism version 8.0. Categorical variables were presented as frequency and percentages (%), and group comparisons were made using the chi-square test or Fisher’s exact test. Continuous variables with normal distributions were described as mean ± standard deviation, non-normal distributions were reported as median (interquartile range), and group comparisons were performed using Student’s t test or the Mann–Whitney U test. Multivariable binary logistic regression analysis was used to assess the independent risk factors for POCs, and the results were presented as odds with 95% confidence intervals. To minimize bias from baseline information and potential confounding factors, propensity score matching (PSM) analysis was performed to obtain matched data. The nearest neighbor matching algorithm was used without replacement for 1:1 matching, and the caliper was set at 0.1 standard deviations. A two-tailed P-value < 0.05 was considered statistically significant.

Ethics statement

This study received approval from the ethics committee of Fujian Cancer Hospital, and all procedures were performed in accordance with the guidelines and regulations of the institution. Consent was provided by all participants after they were fully informed of the study protocol.

Results

POCs and clinicopathological characteristics

A total of 1349 patients who underwent gastrectomy met the eligibility criteria. These patients are divided into a DG group (n = 776) and TG group (n = 573). The overall POCs rate was 21.9% (296/1349), and severe POCs occurred in 131/1349 patients (9.7%).

Risk factors associated with POCs

The POCs and clinicopathological factors are presented in Table 2. For the entire cohort, age, body mass index, diabetes, operation time, and extent of gastrectomy were significantly correlated with overall POCs (all, P < 0.05). Variables in the univariable analysis that showed statistical significance were included as covariates in the multivariable analysis. Age, body mass index, diabetes, operation time, and extent of gastrectomy were identified as independent risk factors for overall POCs in the multivariable analysis (Fig. 2).

Table 2.

Clinicopathological characteristics of patients with or without POCs.

Variable	With POCs (N = 296)	Without POCs (N = 1053)	P value
Age (years)			0.000
< 65	142	629
≥ 65	154	424
Gender			0.482
Male	190	699
Female	106	354
Education			0.610
< High school	235	850
≥ High school	61	203
Marital status, n (%)			0.343
Married	236	865
Spinsterhood/divorced/widowed	60	188
Body mass index (kg/m2)			0.014
< 24	139	579
≥ 24	157	474
Previous abdominal operation			0.093
Yes	61	173
No	235	880
Smoking history			0.091
Yes	83	245
No	213	808
Alcohol history			0.251
Yes	91	288
No	205	765
Diabetes			0.006
Yes	75	191
No	221	862
Hypertension			0.159
Yes	88	270
No	208	783
Dyslipidemia			0.418
Yes	75	243
No	221	810
Tumor location			0.057
Upper-third	77	271
Middle-third	108	315
Lower-third	111	467
Tumor size (cm)			0.047
< 5	144	581
≥ 5	152	472
ASA-classification			0.078
ASA I	198	770
ASA II	63	194
ASA III	35	89
Neoadjuvant chemotherapy			0.297
Yes	86	274
No	210	779
Preoperative hemoglobin, g/L, mean (SD)	127.6 ± 19.3	126.2 ± 17.8	0.234
Preoperative WBC, × 109/L, mean (SD)	6.6 ± 1.9	6.7 ± 2.0	0.488
Preoperative albumin, g/L, median (IQR)	37.9 (35.0, 43.2)	38.0 (34.9,43.6)	0.462
Preoperative BUN, mg/dL, mean (SD)	6.3 ± 1.2	6.2 ± 1.1	0.545
Preoperative total bilirubin, mg/dL, mean (SD)	13.7 ± 4.2	13.6 ± 4.1	0.717
Operation method			0.131
Laparoscopy	145	568
Open	151	485
Operation time (h)			0.012
< 4	174	702
≥ 4	122	351
Estimated blood loss (mL)			0.157
< 200	124	490
≥ 200	172	563
Histological type			0.732
Well/moderately	68	252
Poorly/undifferentiated	228	801
Extent of gastrectomy			0.000
DG	137	628
TG	159	425
Extent of lymph node dissection			0.596
Less than D2	49	161
D2 or more	247	892
Intraoperative blood transfusion			0.246
Yes	64	196
No	232	857
Type of reconstruction			0.785
Roux-en-Y	209	764
Billroth II	29	100
Billroth II with Braun anastomosis	58	189
Reconstruction method			0.588
Intracorporeal	33	106
Extracorporeal	263	947
Number of excised lymph nodes, median (IQR)	33 (24, 42)	31 (23, 40)	0.068
pTNM stagea			0.104
I	68	244
II	64	173
III	164	636

POCs postoperative complications, ASA American Society of Anesthesiologists, SD standard deviation, IQR interquartile range, WBC white blood cell count, BUN blood urea nitrogen, TG total gastrectomy, DG distal gastrectomy.

Figure 2.

Forest plot of the results of the multivariate logistic regression analysis.

Clinicopathological characteristics of patients before and after matching

Age, hypertension, tumor location, preoperative albumin, operation method, operation time, and number of excised lymph nodes differed significantly between the DG group and TG group in the unmatched analysis. After 1:1 PSM, 495 pairs of patients were successfully matched. All baseline characteristics except tumor location were well-balanced between the groups after matching (Table 3).

Table 3.

Comparison of clinical characteristics between the DG group and TG group before and after propensity score matching.

Variable	Before PSM			After PSM
	DG group (N = 765)	TG group (N = 584)	P value	DG group (N = 495)	TG group (N = 495)	P value
Age (years)			0.011			0.201
< 65	460	311		284	264
≥ 65	305	273		211	231
Gender			0.551			0.893
Male	499	390		330	332
Female	266	194		165	163
Education			0.286			0.262
< High school	623	462		405	391
≥ High school	142	122		90	104
Marital status, n (%)			0.708			0.631
Married	637	474		395	401
Spinsterhood/divorced/widowed	138	110		100	94
Body mass index (kg/m2)			0.521			0.849
< 24	413	305		261	258
≥ 24	352	279		234	237
Previous abdominal operation			0.207			0.416
Yes	124	110		88	98
No	641	474		407	397
Smoking history			0.305			0.770
Yes	178	150		123	127
No	587	434		372	368
Alcohol history			0.387			0.358
Yes	222	157		146	133
No	543	427		349	362
Diabetes			0.503			0.270
Yes	146	120		94	108
No	619	464		401	387
Hypertension			0.034			0.199
Yes	186	172		126	144
No	579	412		369	351
Dyslipidemia			0.342			0.229
Yes	173	145		107	123
No	592	439		388	372
Tumor location			0.000			0.000
Upper-third	0	348		0	287
Middle-third	187	236		112	208
Lower-third	578	0		383	0
Tumor size (cm)			0.518			0.278
< 5	417	308		276	259
≥ 5	348	276		219	236
ASA-classification			0.375			0.315
ASA I	559	409		361	344
ASA II	142	115		94	98
ASA III	64	60		40	53
Neoadjuvant chemotherapy			0.311			0.722
Yes	196	164		133	138
No	569	420		362	357
Preoperative hemoglobin, g/L, mean (SD)	126.7 ± 18.6	126.2 ± 17.5	0.616	127.4 ± 18.5	126.6 ± 17.7	0.491
Preoperative WBC, × 109/L (median [IQR])	6.7 ± 1.9	6.6 ± 2.0	0.842	6.7 ± 2.0	6.6 ± 1.9	0.817
Preoperative albumin, g/L, median (IQR)	37.8 (34.5, 43.2)	38.3 (35.4, 43.5)	0.036	38.2(35.3,43.2)	38.0(35.0,43.2)	0.980
BUN, mg/dL, mean (SD)	6.3 ± 1.2	6.2 ± 1.1	0.758	6.3 ± 1.2	6.1 ± 1.0	0.638
Preoperative total bilirubin, mg/dL, mean (SD)	13.6 ± 4.2	13.5 ± 4.1	0.886	13.5 ± 4.1	13.6 ± 4.1	0.538
Operation method			0.040			0.144
Laparoscopy	423	290		267	244
Open	342	294		228	251
Operation time (min)			0.047			0.166
< 4	514	362		324	303
≥ 4	251	222		171	192
Estimated blood loss (mL)			0.279			0.898
< 200	358	256		226	224
≥ 200	407	328		269	271
Histological type			0.399			0.258
Well/moderately	188	132		122	107
Poorly/undifferentiated	577	452		373	388
Extent of lymph node dissection			0.553			0.932
Less than D2	123	87		83	82
D2 or more	642	497		412	413
Intraoperative blood transfusion			0.146			0.268
Yes	137	123		93	107
No	628	461		402	388
Reconstruction method			0.610			0.761
Intracorporeal	76	63		53	56
Extracorporeal	689	521		442	439
Number of excised lymph nodes, median (IQR)	30 (22, 38)	33 (25, 43)	0.000	33 (26, 40)	33 (25, 41)	0.743
pTNM stagea			0.144			0.120
I	174	138		128	111
II	148	89		98	83
III	443	357		269	301

PSM propensity score matching, TG total gastrectomy, DG distal gastrectomy, ASA American Society of Anesthesiologists, SD standard deviation, IQR interquartile range, WBC white blood cell count, BUN blood urea nitrogen.

^aIn accordance with the Eighth American Joint Committee on Cancer classification.

Postoperative outcomes

Compared with the TG group, patients in the DG group had significantly earlier days to first flatus and eating a soft diet, and shorter postoperative hospital stays (P < 0.05). Compared with the DG group, the TG group had higher rates of overall POCs and severe POCs (P < 0.05). In contrast, no significant differences were identified between the groups for the number of days to eating a liquid diet, mortality rate, nutritional markers on postoperative day 7 and the rate of readmission owing to complications within 30 days after discharge (P > 0.05). Table 4 summarizes the postoperative outcomes.

Table 4.

Comparison of postoperative outcomes after matching.

Variable	DG group (n = 495)	TG group (n = 495)	P value
Days of first flatust, days, mean (SD)	3.2 ± 0.9	3.4 ± 0.8	0.007
Days of eating a liquid diet, days, mean (SD)	1.3 ± 0.6	1.4 ± 0.7	0.097
Days of eating a soft diet, days, mean (SD)	5.4 ± 1.1	6.0 ± 1.0	0.000
Postoperative hospital stay, days, mean (SD)	8.5 ± 0.7	8.8 ± 0.9	0.000
Overall POCs			0.000
Yes	114	165
No	382	330
Severe POCs			0.001
Yes	35	67
No	460	428
Mortality			0.478
Yes	3	5
No	492	490
Readmissiona			0.390
Yes	15	20
No	480	475
Total protein postoperative day 7, g/L, median (IQR)	67.3 (62.4, 73.3)	66.1 (61.3, 71.1)	0.052
Albumin on postoperative day 7, g/L, median (IQR)	39.5 (35.7, 45.8)	38.6 (35.6, 43.5)	0.058

TG total gastrectomy, DG distal gastrectomy, SD standard deviation, POCs postoperative complications.

^aReadmission owing to complications within 30 days after discharge.

Subgroup analysis

Table 5 shows that, compared with the DG group, the TG group experienced higher rates of overall POCs and severe POCs, as well as longer postoperative hospital stays in all subgroups (P < 0.05).

Table 5.

Subgroup analyses of postoperative outcomes between the DG group and TG group.

		Patients	Overall POCs		Severe POCs		Hospital stay(days)
			No.	P value	No.	P value		P value
Age (years)
< 65	DG	284	58	0.004	21	0.024	8.5 ± 0.7	0.001
	TG	264	82		35		8.8 ± 0.9
≥ 65	DG	211	56	0.034	14	0.013	8.5 ± 0.7	0.005
	TG	231	83		32		8.8 ± 1.0
Operation method
Laparoscopy	DG	267	61	0.034	18	0.022	8.6 ± 0.8	0.015
	TG	244	76		31		8.8 ± 0.9
Open	DG	228	53	0.003	17	0.016	8.5 ± 0.6	0.000
	TG	251	89		36		8.8 ± 1.0
Tumor location
Upper-third	DG	0	–	–	–	–	–	–
	TG	287	80		39		8.8 ± 0.9
Middle-third	DG	112	18	0.000	6	0.025	8.5 ± 0.7	0.002
	TG	208	85		28		8.8 ± 0.8
Lower-third	DG	383	96	–	29	–	8.5 ± 0.8	–
	TG	0	–		–		–

TG total gastrectomy, DG distal gastrectomy, POCs postoperative complications.

Discussion

Despite remarkable advancements in perioperative care, and surgical and anesthetic procedures, gastrectomy is still associated with a high percentage of POCs. In this study, of the 1349 enrolled patients, 296 (21.9%) had POCs, and 131 (9.7%) had severe POCs. POCs rates varied widely in previous studies. Kurokawa et al.³⁰ demonstrated that the POCs incidence was 12.2% in 1456 patients with pT2–T4 gastric cancer. Liu et al.³¹ reported a POCs rate of 27.8% after gastric cancer resection. Kurita et al.³² showed that the overall morbidity rate in the DG population was 18.3%. Goglia et al.³³ reported an overall POCs rate of 33.0%, with 17.0% of the patients having a complication classified as Clavien–Dindo grade ≥ III. The reasons for this variability in POCs rates may be differences in the definitions of POCs, type of gastrectomy, ethnic group, clinicopathological characteristics, and surgeons’ experience.

POCs are a crucial aspect in evaluating the safety and technical viability of an operation. Undoubtedly, POCs can seriously prolong postoperative recovery, increase length of hospital stay and costs, delay the initiation of adjuvant chemotherapy, and affect patients’ quality of life³⁴. Moreover, POCs adversely influence recurrence and long-term survival, even if the tumor is resected curatively^{26,27,35–38}. Given the high incidence and considerable impact of POCs, we evaluated POCs as the primary outcome in this study. Multivariate analysis revealed that TG was an independent risk factor for overall POCs, consistent with findings in previous studies^35,39,40.

In our study, differences were observed between the DG and TG groups for age, hypertension, tumor location, preoperative albumin, operation method, operation time, and number of excised lymph nodes, before matching. In previous studies, age, preoperative albumin, operation method, and operation time were identified as factors influencing the postoperative recovery time of patients with gastric cancer^35,41–44. We used PSM analysis to minimize selection bias and confounding, in this study. After PSM, the baseline characteristics were comparable between the two groups, except for tumor location. Because we performed DG and TG for patients with lower-third and upper-third gastric cancer, respectively, it was not possible to perform PSM analysis for tumor location. In this study, higher rates of both overall- and severe POCs were observed in the TG group compared with the DG group. Additionally, we found that DG patients experienced a significantly earlier onset of first flatus, started eating a soft diet sooner, and had shorter postoperative hospital stays compared with the TG group. These findings are attributed to the fact that the DG group experienced an earlier onset of first flatus, leading to a shorter time required to transition from a liquid diet to a soft diet.

With rapid advancements in laparoscopic instruments and techniques over the past decade, laparoscopic surgery has been widely adopted for the treatment of both early and advanced gastric cancer^45–48. The scope of resection is no longer limited to DG^49–51. Compared with open surgery, the laparoscopic approach offers several notable advantages, namely faster recovery, less postoperative pain, shorter hospital stay, and comparable long-term oncological outcomes^52–54. In this study, compared with the DG group, the TG group was consistently associated with a higher rate of overall POCs and longer postoperative hospital stay in the subgroup analyses based on the operation method.

Owing to small stomach volume, malabsorption, increased catabolism resulting from surgical stress, reduced physical activity, and other factors, many patients who undergo gastrectomy experience deficiencies in iron and/or vitamin B12, and malnutrition^55–57. Previous retrospective studies have shown that DG is associated with better postoperative nutritional status compared with TG^58–60. In this study, although total protein and albumin levels were lower in the TG group compared with the DG group, the differences were not statistically significant. This can be attributed to the fact that this study focused on short-term outcomes (to postoperative day 7). The human body has a certain amount of nutritional reserves, particularly in the liver and muscle tissues, which can sustain serum albumin and total protein levels for a short time after surgery. During the initial postoperative period, patients typically receive adequate perioperative nutritional support, which helps maintain a relatively stable nutritional status in the short-term and potentially masks early nutritional deficiencies.

While consensus guidelines for ERAS in gastrectomy patients were issued by the ERAS Society in 2014, ongoing debate and challenges persist in clinical surgical practice⁶¹. A multicenter study performed in Western populations revealed only moderate compliance with the ERAS protocols⁶². One possible reason is that the application of ERAS programs does not distinguish between TG and DG.

Compared with DG, TG remains a more challenging procedure owing to its higher technical complexity and the trauma associated with the excision of a greater number of lymph nodes and more tissue. This results in a postoperative inflammatory response, and occasional damage to blood vessels could lead to an increased risk of intra-abdominal bleeding after surgery^18,63. Additionally, esophagojejunal anastomosis is a crucial step in TG. Reconstruction of the digestive tract in TG is performed in a limited operating space and involves deep anastomosis; therefore TG is more complex and challenging compared with the gastrojejunal anastomosis in DG. This is particularly true in patients with large amounts of visceral fat. Excessive pulling and tension on the anastomosis can lead to tearing and bleeding of the serosa^64–66.

The extent of gastrectomy for resectable gastric cancer depends on the comprehensive consideration of tumor size, location, clinical stage, surgeons’ experience, and the distance from the proximal resection margin. Currently, consensus on the optimal extent of gastrectomy (total or subtotal) for middle-third gastric cancer is yet to be established⁶⁷. Therefore, we performed subgroup analyses for middle-third gastric cancer. The results showed that the TG group experienced a higher rate of overall POCs and longer postoperative hospital stay, compared with the DG group. Similar results have been reported in previous studies that showed that DG is superior to TG when evaluating intraoperative and short-term outcomes^17,65,66. Moreover, previous studies suggested that TG had a detrimental impact on patients’ long-term health-related quality of life and was associated with more post-gastrectomy symptoms at one or all time points, compared with DG^19,20. We consider that DG is safe and reasonable for middle-third gastric cancer under the precondition of negative proximal resection margins.

There are several limitations in our study. First, compared with TG, DG for middle-third gastric cancer was associated with better short-term outcomes. However, comparisons of long-term survival rates, cancer recurrence rates, loss of body weight, physical activity, and quality of life were lacking. Second, although this study was performed at a high-volume center, this was s a single-center study comparing TG and DG, which may limit the generalizability of the findings. Therefore, a large multicenter approach is necessary for further validation of our results. Finally, robotic computer-assisted platforms for gastric cancer were introduced at our institution in 2020, but only a small percentage of patients have been able to undergo robotic surgery owing to the high cost. Surgeons’ experience is an independent risk factor for POCs⁶⁸. To reduce the occurrence of POCs that result from a lack of experience, surgeons should consider selecting patients who are in good health, during the surgeons’ initial stages of learning robotic gastrectomy. The exclusion criteria in this study included patients who had undergone robotic gastrectomy to mitigate bias in the study. However, it is important to note that this exclusion could potentially limit the generalizability of the study’s findings.

In conclusion, despite similar mortality and readmission rates compared with TG, DG offers the advantages of quicker bowel function recovery, fewer POCs, and a shorter hospital stay under ERAS. The ERAS guidelines for gastrectomy recommend an early postoperative oral diet regardless of the extent of gastric resection. However, it may be advisable to restart oral nutrition cautiously and gradually increase intake for patients who have undergone TG.

Author contributions

M.F.Y. and Y.M.L. designed the study. M.F.Y., Z.Y.L, Y.P.X., H.Z.Z., Y.Z.P., and C.K.Y. collected and analyzed the data. Z.M.L. and Z.Y.L. wrote the manuscript. M.F.Y. and Z.Y.L. reviewed the manuscript. C.K.Y. and Y.M.L. prepared the figures. All authors approved the final manuscript.

Funding

This study was supported by the Startup Fund for scientific research, Fujian Medical University (Grant Numbers: 2022QH1158, 2020QH1226) and the Fujian Cancer Hospital Project (Grant Number: 2024YN01) and was sponsored by the Fujian Provincial Health Technology Project (Grant Number: 2022TG016).

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare no competing interests.