Abstract
To evaluate safety and efficacy of laparoscopy-assisted radical gastrectomy (LARG) for advanced gastric cancer patients aged 70 years or older. Clinical data were retrospectively collected from patients with IIA-IIIC gastric cancer who underwent LARG (n = 30) and open radical gastrectomy (ORG, n = 34) in Department of Gastrointestinal Surgery in the Ningbo First Hospital from January 2012 to December 2013. The mean operative time was longer in the LARG group than in the ORG group but there was no statistical difference between the two groups. The intraoperative blood loss (120 ± 52.7 ml vs 227.3 ± 146.9 ml), incidence of postoperative complication (23.0% vs 47%) were lower in the LARG group than those in the ORG group. In addition, the time to first flatus (2.9 ± 0.8 d vs 4.6 ± 1.2 d), time to first ambulation (1.2 ± 0.4 vs 4.1 ± 1.0 d), time of nasogastric intubation (2.5 ± 1.0 d vs 3.5 ± 1.4 d), and postoperative hospital stay (13.0 ± 4.2 d vs 16.9 ± 4.1 d) were significantly shorter in the LARG group than in the ORG group, respectively. No statistical difference in the number of harvested lymph nodes was noted between the two groups (30.2 ± 12.0 vs 28.1 ± 11.8, P > 0.05). LARG is safer, more effective and less invasive for the elderly patients with advanced gastric cancer.
Keywords: Laparoscopy-assisted gastrectomy, open gastrectomy, gastric cancer, clinical efficacy
Introduction
According to the “Statistical Communiqué of the People’s Republic of China on the 2013 Social Service and Development” published by Ministry of Civil Affairs of China, 131.61 milllion people were aged 65 and over (9.7% of the total population) by the end of 2013 [1]. It is predicted that both the population and the proportion of elderly will continue to increase in China.
Gastric cancer is one of the most common malignant tumors worldwide, with a yearly incidence of about 900000. In China, more than 400000 cases of gastric cancer are diagnosed annually, of them, more than 90% are diagnosed at an advanced stage when they first present [2]. With the changing age distribution, the number of elderly patients with gastric cancer is increasing, especially in China. At present, radical D2 gastrectomy is the only effective treatment for gastric cancer with a potential to cure the disease [3]. Several previous studies have reported a high incidence of comorbid disease, postoperative complications, and mortality associated with elderly gastric cancer patients who have undergone open gastrectomy [4,5]. Laparoscopy-assisted radical gastrectomy (LARG) has been reported as a less invasive surgical technique than open gastrectomy in terms of reduced postoperative morbidity, rapid return of gastrointestinal function, shortened hospital stay after operation, thus is a widely accepted treatment for gastric cancer nowadays [6-8]. On the other hand, disadvantages of LARG were also reported such as longer operation times and usually requiring a pneumoperitoneum, which can influence respiratory or cardiovascular function especially for those elderly patients who often have preoperative morbidities and reduced functional capacities [9,10]. Therefore, the feasibility of LARG in elderly patients is still controversial. Some studies have suggested that LARG is an effective treatment for elderly patients with early gastric cancer [11,12]. However, its suitability for the treatment of elderly patients with advanced gastric cancer has not previously been tested. The current study compared the surgical short-term outcomes between LARG and open radical gastrectomy (ORG) cancer in elderly patients with advanced gastric cancer in our department.
Material and methods
Patient clinical data
A total of 103 patients aged ≥ 70 years with gastric cancer were treated with LARG or ORG in our Department from January 2012 to December 2013. Of those, 64 patients with IIA-IIIC gastric cancer were enrolled in this study, of which 30 patients were underwent LARG, and 34 patients were underwent ORG. The other 43 patients with stage I or IV who had not been undergone radical gastrectomy with D2 lymph nodes dissection were excluded. The study including data collection and data analysis was approved by the Ethics Committee of Ningbo First Hospital, and all enrolled patients provided written informed consent. All the patients were confirmed pathologically as gastric adenocarcinoma at staging IIA-IIIC based on the 2010 World Health Organization (WHO) classification [13]. Preoperative, intraoperative and postoperative parameters were compared between the LARG group and ORG group.
Preoperative evaluation of general condition
Chest X-rays, laboratory tests, electrocardiograms (ECG), echocardiography, computed tomography of the abdomen and respiratory function tests using spirometry were examined in all patients to assess preoperative cardiopulmonary function and other comorbidities. Patients were classified according to the American Society of Anesthesiologists (ASA) Classification of Physical Status guidelines so that patient comorbidity could be evaluated objectively.
Surgical procedures
LARG
Following general anesthesia, patients were placed in the supine position with their legs apart. LARG was performed under a pneumoperitoneum that was created by injection of carbon dioxide (CO2) at 10-12 mmHg during surgery. However, an intraperitoneal pressure of 8-10 mmHg was sometimes selected if a lower cardiopulmonary reserve was expected. A total of five ports (each 5-12 mm) were inserted, and the operator was standing on the left side of the patient, while first assistant was standing on the right side, and the second assistant who was holding the laparoscope stood between the patient’s legs. The procedure of LARG was conducted briefly as follows. After completion of the omentectomy, the roots of the right gastroepiploic vein and artery were isolated and sealed by harmonic scalpel with clips and lymph nodes (Group 6) were removed. Then, along the dissection of pancreatic capsule, the splenic artery, left gastric artery, left gastric vein and the common hepatic artery were exposed with the lymph nodes (Group 11p, 7, 8, 9) dissected; Along the gastroduodenal artery, the root of the right gastric artery and proper hepatic artery were exposed and the lymph nodes (Group 5, 12a) were dissected. Next, the lesser omentum was dissected from the lesser curvature, then left gastroepiploic artery and vein were dissedted after the isolation of splenic flexure with resection of the greater omentum from the greater curvature of the stomach (Group 1, 3, 4), thus the lymph node dissection was completed intracorporeally for radical distal gastrectomy. As to radical total gastrectomy, procedures were needed to further isolate the splenic flexure, and the short gastric vessels were resected at the origin. The splenic artery was isolated and the lymph nodes of Group 11 d and 10 were removed. After isolation of stomach from the gastric fundus and posterior stomach, 5 cm of the esophagus was exposed with the anterior and posterior vagal nerves resected, then the lymph nodes of Group 1 and 2 were dissected. Extrocorporeal reconstruction was performed using a 4-5 cm upper midline incision with Billroth-I or II for distal gastrectomy or Roux-en-Y reconstruction for total gastrectomy.
ORG
The operation was carried out under general anesthesia. Patients were placed in the supine position. An incision of 15-20 cm was made in the midline of the upper abdomen. The procedure of open radical gastrectomy was performed as described above.
Statistical analysis
Statistical analysis was performed using SPSS 18.0 (SPSS Inc., Chicago, IL, United States). All data are presented as mean ± SD, and were analyzed using Student’s t test. Categorical data are presented as proportions, and were analyzed using the Chi square test or Fisher exact probability test. P < 0.05 was considered statistically significant.
Results
Patient characteristics
Patient demographics and clinical findings are listed in Table 1. Hypertension, chronic obstructive pulmonary disease (COPD), cardiovascular disease and diabetes mellitus were the most common comorbid diseases in both groups, but the distribution of comorbid diseases did not differ between the two groups. There were no significant differences with respect to other preoperative characteristics and postoperative pathologic features between the two groups.
Table 1.
The characteristics of the included patients
| LARG (n = 30) | ORG (n = 34) | P value | |
|---|---|---|---|
| Age (year) | 74.4 ± 3.1 | 75.6 ± 3.0 | P = 0.132 |
| Gender (M/F) | 25/5 | 22/12 | P = 0.092 |
| BMI (kg/m2) | 21.6 ± 2.7 | 21.6 ± 3.0 | P = 0.960 |
| Comorbidity | |||
| Hypertension | 15 | 16 | P = 0.814 |
| Diabetes mellitus | 3 | 5 | P = 0.850 |
| COPD | 6 | 6 | P = 0.810 |
| Heart disease | 10 | 7 | P = 0.249 |
| ASA-PS | P = 0.995 | ||
| 1 | 1 | 1 | |
| 2 | 21 | 24 | |
| 3 | 8 | 9 | |
| Tumor location | P = 0.313 | ||
| Upper | 3 | 6 | |
| Middle | 11 | 7 | |
| Lower | 16 | 21 | |
| Type of operation | P = 0.146 | ||
| Distal gastrectomy | 14 | 22 | |
| Total gastrectomy | 16 | 12 | |
| Intraoperative PaCO2 (mmHg) | 42.3 ± 5.7 | 38.1 ± 4.5 | P = 0.004 |
| Preoperative Hb (g/dl) | 9.0 ± 2.4 | 8.7 ± 1.5 | P = 0.600 |
| Postoperative Hb (g/dl) | 10.5 ± 2.3 | 10.1 ± 1.9 | P = 0.428 |
| Preoperative serum albumin (g/dl) | 36.9 ± 4.3 | 35.5 ± 5.5 | P = 0.297 |
| Postoperative serum albumin (g/dl) | 29.7 ± 3.6 | 29.3 ± 3.7 | P = 0.727 |
| Tumor size (cm) | 4.1 ± 1.9 | 4.9 ± 2.6 | P = 0.153 |
| Tumor stage | P = 0.065 | ||
| IIA-IIB | 16 | 10 | |
| IIIA-IIIB | 5 | 14 | |
| IIIC | 9 | 10 |
Comparison of intraoperative characteristics and outcomes
LARG was successfully completed in the 30 patients without conversion to laparotomy. ORG was also successfully performed in 34 patients. Surgical indices are shown in Table 2. The mean operative time was a little longer in the LARG group than that in the ORG group (259.5.3 ± 53.76 min vs 236.09 ± 45.3 min, p > 0.05), but there was no significant difference between the two groups. There were no significant differences in the mean number of retrieved lymph nodes between the two groups (30.2 ± 12.0 vs 28.1 ± 11.8, p > 0.05). Whereas patients in the LARG group showed less intraoperative blood loss (120 ± 52.7 ml vs 227.3 ± 146.9 ml, p < 0.05), shorter time of nasogastric intubation (2.5 ± 1.0 d vs 3.5 ± 1.4 d), shorter time to first flatus (2.9 ± 0.8 d vs 4.6 ± 1.2 d), decreased time to first ambulation (1.2 ± 0.4 vs 4.1 ± 1.0 d), less time to initiate oral intake (4.5 ± 0.8 d vs 5.5 ± 1.0 d), and less postoperative hospital stay (13.0 ± 4.2 d vs 16.9 ± 4.1 d, p < 0.05). than those in the ORG group. The intraoperative arterial blood partial pressure of CO2 (PaCO2) was higher in the LARG group than that in the ORG group (42.3 ± 5.7 mmHg vs 38.1 ± 4.5 mmHg, P < 0.05).
Table 2.
Comparison of surgical outcomes between LARG and ORG
| Outcomes | LARG (n = 30) | ORG (n = 34) | P value |
|---|---|---|---|
| Operative time (min) | 259.5 ± 53.76 | 236.09 ± 45.3 | P = 0.068 |
| Blood loss | 120 ± 52.7 | 227.3 ± 146.9 | P < 0.01 |
| Number of retrieved lymph nodes | 30.2 ± 12.0 | 28.1 ± 11.8 | P = 0.484 |
| Time to first flatus (d) | 2.9 ± 0.8 | 4.6 ± 1.2 | P < 0.010 |
| Time of nasogastric intubation (d) | 2.5 ± 1.0 | 3.5 ± 1.4 | P < 0.01 |
| Time to initiate oral intake (d) | 4.5 ± 0.8 | 5.5 ± 1.0 | P < 0.01 |
| Time to ambulation (d) | 1.2 ± 0.4 | 4.1 ± 1.0 | P < 0.01 |
| Hospital stay (d) | 13.0 ± 4.2 | 16.9 ± 4.1 | P < 0.01 |
Postoperative complications
Postoperative complications are listed in Table 3. The overall complication rate was significantly lower in the LARG group than that in the ORG group (23%, 7/30 vs 47%, 16/34, P < 0.05). The most frequent complications were respiratory or cardiovascular complications. One patient in the ORG group developed anastomotic leakage requiring image-guided drainage after esophagojejunostomy. No patient in the two groups needed a re-operation due to postoperative complication and no perioperative death occurred in either group.
Table 3.
Comparison of postoperative complications
| Postoperative complications | LARG (n = 30) | ORG (n = 34) | P value |
|---|---|---|---|
| Overall, n (%) | 7 (23) | 16 (47) | P = 0.048 |
| Anastomotic leakage (n) | 0 | 1 | p = ? |
| Pulmonary infection (n) | 3 | 7 | p = ? |
| Re-operation | 0 | 0 | 0 |
| Incision infection | 1 | 0 | p = ? |
| Urinary infection | 1 | 2 | p = ? |
| Heart failure | 0 | 3 | p = ? |
| Others | 2 | 3 | p = ? |
Discussion
Since the first successful LARG by Kitano et al [14] for early gastric cancer in 1994, LARG has been widely accepted modality for early gastric cancer in Japan and Korea [15]. Whether LARG can be applied in the treatment of advanced gastic cancer is still controversial. Park et al [16] evaluated the long-term results of 239 patients who underwent LARG for the treatment of advanced gastric cancer and found that the major recurrence was distant metastasis whereas lymph node relapses were most frequent in para-aortic lymph node metastasis, thus believing that the dissection of lymph nodes around the stomach can be performed efficiently by LARG. Chen et al [17] made a systematic review and meta-analysis of laparoscopic and open gastrectomy for advanced gastric cancer, and alternative suggested that LARG is a safe technical alternative to ORG for advanced gastric cancer with a lower complication rate and enhanced postoperative recovery.
With the aging population, more elderly patients with advanced gastric cancer are being referred for radical gastric resection. Previous studies reported an adverse effect with high incidences of postoperative morbidity and mortality among elderly gastric cancer patients who undergone ORG [4,5], therefore, the minimally invasive surgical procedure LARG which has many advantages such as less pain, less intraoperative bleeding, earlier bowel movements and postoperative recovery, is recommended for those older patients with a higher incidence of comorbid disease [18].
Although the World Health Organization defines elderly patients as those over 65 years of age, in the present study, elderly patients were defined as being 70 years old or older as other studies reported [19,20]. Some studies reported that the incidence of postoperative complications after ORG in elderly patients was higher than that in younger patients due to preoperative comorbidities mainly including hypertension, COPD, cardiovascular disease and diabetes mellitus as revealed in present study [21,22]. However, when taken the severity of postoperative complications into consideration, there was no statistical difference in the rates of postoperative complications between the elderly patients and young patients if the patients undergoing LARG [18]. Outcomes in the current study demonstrated that postoperative complication rate was quite lower in the LARG group than that in ORG group (23% vs 47%), and we consider that the decrease in postoperative morbidity particularly in respiratory complications is mainly attributed to the minimally invasive surgical procedure, because LARG is less painful, less intraoperative blood loss, earlier ambulation and shorter nasogastric intubation , all of which are crucial for better recovery for elderly patients.
It is also important to consider the potential negative effects of the pneumoperitoneum on cardiopulmonary reserve during LARG surgery particularly for elderly patients, which can cause severe arrhthmia, decreased mean arterial blood pressure, and systemic vascular pressure. Normally, an intraperitoneal pressure of 10-12 mmHg was maintained during operation, but sometimes an intraperitoneal pressure of 8-10 mmHg was also selected for those limited cardiopulmonary reserve patients in order to reduce the pneumoperitoneum-related negative effects [23]. Operative time of LARG is another important factor concerning the negative effects of the pneumoperitoneum on patients’ cardiopulmonary function [24]. However, as the technique improved and experience accumulated, the LARG operation time is similar to that of ORG [25]. In the present study, the operative time of LARG and ORG was 259.5.3 ± 53.76 min and 236.09 ± 45.3 min respectively, a little longer in the LARG group than that in the ORG group with no statistically significant difference between the two groups. Therefore, in our series, we did not experience any elderly patients who suffered from severe accidents related to the pneumoperitoneum during LARG although the intraoperative arterial blood partial pressure of CO2 (PaCO2) was higher in the LARG group than that in the ORG group.
The result that there were no significant differences in the mean number of retrieved lymph nodes between the two groups suggested that LARG can achieve the same D2 lymph node dissection effect as to that by ORG. Other early surgical outcomes demonstrated that LARG is a safe, effective, and minimally invasive approach for treatment of elderly patients with advanced gastric cancer.
There are some limitations associated with the present study. The long-term efficacy of LARG in elderly patients with advanced gastric cancer is needed to observe, and large-volume studies are also needed to further investigate.
In conclusion, with the advances in surgical technology, improved treatments for momorbid diseases, and appropriate prophylaxis of morbidity, the present study revealed satifactory short-term surgical outcomes after LARG compared to ORG in elderly patients with advanced gastric cancer. LARG should be considered as a treatment of choice in elderly patients with advanced gastric cancer.
Disclosure of conflict of interest
None.
References
- 1.Statistical Communiqué of the People’s Republic of China on the Social Service and Development. Available from: URL: http://www.gov.cn.
- 2.Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63:11–30. doi: 10.3322/caac.21166. [DOI] [PubMed] [Google Scholar]
- 3.Ajani JA, Bentrem DJ, Besh S, D’Amico TA, Das P, Denlinger C, Fakih MG, Fuchs CS, Gerdes H, Glasgow RE, Hayman JA, Hofstetter WL, Ilson DH, Keswani RN, Kleinberg LR, Korn WM, Lockhart AC, Meredith K, Mulcahy MF, Orringer MB, Posey JA, Sasson AR, Scott WJ, Strong VE, Varghese TK, Warren G, Washington MK, Willett C, Wright CD, McMillian NR, Sundar H. Gastric cancer, version 2.2013: featured updates to the NCCN Guidelines. J Natl Compr Canc Netw. 2013;11:531–546. doi: 10.6004/jnccn.2013.0070. [DOI] [PubMed] [Google Scholar]
- 4.Kitamura K, Yamaguchi T, Taniguchi H, Hagiwara A, Yamane T, Sawai K, Takahashi T. Clinicopathological characteristics of gastric cancer in the elderly. Br J Cancer. 1996;73:798–802. doi: 10.1038/bjc.1996.139. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Eguchi T, Fujii M, Takayama T. Mortality for gastric cancer in elderly patients. J Surg Oncol. 2003;84:132–136. doi: 10.1002/jso.10303. [DOI] [PubMed] [Google Scholar]
- 6.Kim MC, Kim KH, Kim HH, Jung GJ. Comparison of laparoscopy-assisted by conventional open distal gastrectomy and extraperigastric lymph node dissection in early gastric cancer. J Surg Oncol. 2005;91:90–94. doi: 10.1002/jso.20271. [DOI] [PubMed] [Google Scholar]
- 7.Mochiki E, Kamiyama Y, Aihara R, Nakabayashi T, Asao T, Kuwano H. Laparoscopic assisted distal gastrectomy for early gastric cancer: Five years’ experience. Surgery. 2005;137:317–322. doi: 10.1016/j.surg.2004.10.012. [DOI] [PubMed] [Google Scholar]
- 8.Li HT, Han XP, Su L, Zhu WK, Xu W, Li K, Zhao QC, Yang H, Liu HB. Short-term efficacy of laparoscopy-assisted vs open radical gastrectomy in gastric cancer. World J Gastrointest Surg. 2014;6:59–64. doi: 10.4240/wjgs.v6.i4.59. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Sakuramoto S, Kikuchi S, Kuroyama S, Futawatari N, Katada N, Kobayashi N, Watanabe M. Laparoscopy-assisted distal gastrectomy for early gastric cancer: experience with 111 consecutive patients. Surg Endosc. 2006;20:55–60. doi: 10.1007/s00464-005-0126-5. [DOI] [PubMed] [Google Scholar]
- 10.Haris SN, Ballantyne GH, Luther MA, Perrino AC Jr. Alterations of cardiovascular permormance during laparoscopic colectomy: a combined hemodynamic and echocardiographic analysis. Anesth Analg. 1996;83:482–487. doi: 10.1097/00000539-199609000-00007. [DOI] [PubMed] [Google Scholar]
- 11.Yasuda K, Sonoda K, Shiroshita M, Inomata M, Shiraishi N, Kitano S. Laparoscopically assisted distal gastrectomy for early gastric cancer in the elderly. Br J Surg. 2004;91:1061–1065. doi: 10.1002/bjs.4615. [DOI] [PubMed] [Google Scholar]
- 12.Mochiki E, Ohno T, Kamiyama Y, Aihara R, Nakabayashi T, Asao T, Kuwano H. Laparoscopy-assisted gastrectomy for early gastric cancer in young and elderly patients. World J Surg. 2005;29:1585–1591. doi: 10.1007/s00268-005-0208-5. [DOI] [PubMed] [Google Scholar]
- 13.Li ZS, Li Q. The latest 2010 WHO classification of tumors of digestive system. Zhonghua Binglixue Zazhi. 2011;40:351–354. [PubMed] [Google Scholar]
- 14.Kitano S, Iso Y, Moriyama M, Surgimachi K. Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc. 1994;4:146–148. [PubMed] [Google Scholar]
- 15.Kim HH, Hyung WJ, Cho GS, Kim MC, Han SU, Kim W, Ryu SW, Lee HJ, Song KY. Morbidity and mortality of laparoscopic gastrectomy versus open gastrectomy for gastric cancer: an interim report-a phase III multicenter, prospective, randomized Trial (KLASS Trial) Ann Surg. 2010;251:417–420. doi: 10.1097/SLA.0b013e3181cc8f6b. [DOI] [PubMed] [Google Scholar]
- 16.Park do J, Han SU, Hyung WJ, Kim MC, Kim W, Ryu SY, Ryu SW, Song KY, Lee HJ, Cho GS, Kim HH. Long-term outcomes after laparoscomy-assisted gastrectomy for advanced gastric cancer: a large-scale multicenter retrospective study. Surg Endosc. 2012;26:1548–1553. doi: 10.1007/s00464-011-2065-7. [DOI] [PubMed] [Google Scholar]
- 17.Chen K, Xu XW, Mou YP, Pan Y, Zhou YC, Zhang RC, Wu D. Systemtic review and meta-analysis of laparoscopic and open gastrectomy for advanced gastric cancer. World J Surg Oncol. 2013;11:182. doi: 10.1186/1477-7819-11-182. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Kim KH, Kim MC, Jung GJ. Is the rate of postoperative complications following laparoscopy-assisted gastrectomy higher in elderly patients than in young patients? World J Surg Oncol. 2014;12:97–103. doi: 10.1186/1477-7819-12-97. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Mochiki E, Ohno T, Kamiyama Y, Aihara R, Nakabayashi T, Asao T, Kuwano H. Laparoscopy-assisted gastrectomy for early gastric cancer in young and elderly patients. World J Surg. 2005;29:1585–1591. doi: 10.1007/s00268-005-0208-5. [DOI] [PubMed] [Google Scholar]
- 20.Kumagai K, Hiki N, Nunobe S, Jiang X, Kubota T, Aikou S, Tanimura S, Sano T, Yamaguchi T. Potentially fatal complications for elderly patients after laparoscopy-assisted distal gastrectomy. Gastric Cancer. 2014;17:548–55. doi: 10.1007/s10120-013-0292-4. [DOI] [PubMed] [Google Scholar]
- 21.Wu CW, Lo SS, Shen KH, Hsieh MC, Lui WY, P’Eng FK. Surgical mortality, survival, and quality of life after resection for gastric cancer in the elderly. World J Surg. 2000;24:465–472. doi: 10.1007/s002689910074. [DOI] [PubMed] [Google Scholar]
- 22.Bittner R, Butters M, Ulrich M, Uppenbrink S, Beger HG. Total gastrectomy. Updated operative mortality and long-term survival with particular reference to patients older than 70 years of age. Ann Surg. 1996;224:37–42. doi: 10.1097/00000658-199607000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Yamada H, Kojima K, Inokuchi M, Kawano T, Sugihara K. Laparoscopy-assisted gastrectomy in patients older than 80. J Surg Res. 2010;161:259–263. doi: 10.1016/j.jss.2009.01.032. [DOI] [PubMed] [Google Scholar]
- 24.Tokunaga M, Hiki N, Fukunaga T, Miki A, Ohyama S, Seto Y, Yamaguchi T. Does age matter in the indication for laparoscopy-assisted gastrectomy? J Gastrointest Surg. 2008;12:1502–1507. doi: 10.1007/s11605-008-0567-y. [DOI] [PubMed] [Google Scholar]
- 25.Lin JX, Huang CM, Zheng CH, Li P, Xie JW, Wang JB, Lu J. Laparoscopy-assisted gastrectomy with D2 lymph node dissection for advanced gastric cancer without serosa invasion: a matched cohort study from South China. World J Surg Oncol. 2013;11:4. doi: 10.1186/1477-7819-11-4. [DOI] [PMC free article] [PubMed] [Google Scholar]