{"paper_id":"1d6f039e-dc89-4c34-b33c-aff6763de22a","body_text":"Optimization of Anastomotic Strategy in Totally Laparoscopic Gastric Cancer Surgery Based on Dynamic Inflammatory Response Trajectories: A Prospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Optimization of Anastomotic Strategy in Totally Laparoscopic Gastric Cancer Surgery Based on Dynamic Inflammatory Response Trajectories: A Prospective Cohort Study zhiqiang wang, jian Tang, qiuyue she, zhiyuan guo, linsen zhou, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8645414/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Apr, 2026 Read the published version in BMC Surgery → Version 1 posted 13 You are reading this latest preprint version Abstract Objective Although laparoscopic surgery for gastric cancer has matured, the selection of the optimal anastomotic method (circular stapler [CS] vs. linear stapler [LS]) remains lacking in objective evidence based on patient biological responses. This study prospectively evaluated the dynamic changes in perioperative systemic inflammatory responses and their implications for guiding the choice of surgical approach (totally laparoscopic distal gastrectomy [TLDG] vs. totally laparoscopic total gastrectomy [LTG]) and anastomotic technique. Methods This prospective observational cohort study enrolled 180 patients undergoing radical laparoscopic gastrectomy. Patients were divided into four groups: TLDG-CS (n = 50), TLDG-LS (n = 50), LTG-CS (n = 40), and LTG-LS (n = 40). The CS groups underwent anastomosis using a novel laparoscopic purse-string suture clamp (Lap-PSC) combined with a multi-functional sealing cap (MSC). Serum levels of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and high-sensitivity C-reactive protein (hs-CRP) were measured preoperatively (T0), and at 24 hours (T1), 72 hours (T2), and 7 days (T3) postoperatively. The primary endpoint was the dynamic trajectory of inflammatory markers; secondary endpoints included surgical outcomes, postoperative recovery, and complications. Results Baseline characteristics were balanced among groups. Operative time was significantly shorter in the TLDG-CS group compared to TLDG-LS (148.3 ± 21.5 vs. 172.8 ± 28.4 minutes, p = 0.003). Inflammatory markers peaked at T1 and declined thereafter. At T2, IL-6 and hs-CRP levels were significantly lower in CS groups compared to LS groups for both TLDG and LTG (e.g., TLDG-CS vs. TLDG-LS IL-6: 82.4 ± 28.1 vs. 115.6 ± 35.7 pg/mL, p < 0.001). Multivariate linear regression confirmed that LS was an independent predictor of higher IL-6 (β = 28.4, 95%CI: 15.7–41.1, p < 0.001) and hs-CRP (β = 12.3, 95%CI: 6.8–17.8, p < 0.001) at T2. The overall anastomosis-related complication rate was significantly lower in the CS group (3.3% vs. 8.9%, p = 0.048). Conclusion Dynamic perioperative inflammatory responses are sensitive indicators of surgical trauma and prognosis. In totally laparoscopic gastric cancer surgery, circular stapling assisted by Lap-PSC and MSC significantly attenuates systemic inflammatory responses and is associated with a lower risk of anastomotic complications compared to linear stapling. Monitoring inflammatory dynamics may provide an objective biological basis for personalized surgical-anastomotic strategy selection, advancing gastric cancer surgery toward greater precision. Gastric cancer Perioperative inflammatory response Anastomotic technique Interleukin-6 C-reactive protein Background Gastric cancer remains one of the most common and lethal malignancies worldwide. According to GLOBOCAN 2022, it ranks as the fifth most common cancer and the fifth leading cause of cancer-related mortality, with nearly one million new cases and over 650,000 deaths annually. In China, despite a declining incidence, the disease burden remains substantial, with 358,700 new cases and 260,400 deaths reported in 2022, ranking fifth in incidence and third in mortality among all cancers [ 1 , 2 ] . Surgical resection remains the cornerstone of curative treatment, and the introduction of laparoscopic techniques has revolutionized its practice. Since the first report of laparoscopic-assisted distal gastrectomy by Kitano et al. in 1994, several high-quality randomized controlled trials—including the Japanese JCOG0912, Korean KLASS-01, and Chinese CLASS-01 studies—have established the non-inferiority, and in some perioperative outcomes, superiority of laparoscopic distal gastrectomy over open surgery for early and locally advanced gastric cancer [ 3 – 6 ] . Within the framework of laparoscopic gastric surgery, the choice of digestive reconstruction method, particularly the anastomotic technique, critically influences postoperative functional recovery and complication rates. Circular stapler (CS) and linear stapler (LS) anastomoses are the two main techniques, each with theoretical advantages and clinical challenges. CS anastomosis, considered the “gold standard” in the open surgery era, is known for creating stable-caliber, well-vascularized end-to-end or end-to-side anastomoses [ 7 – 9 ] . However, performing precise purse-string sutures in a totally laparoscopic setting has long been a technical bottleneck. Consequently, several intracorporeal linear anastomotic techniques—such as Delta anastomosis, triangular stapling technique (TST), self-pulling and latter transection Delta anastomosis (Delta SPLT), and the Billroth I anastomosis with rectangular transection (Billroth I-ART)—have been developed to facilitate laparoscopic reconstruction [ 10 , 11 ] . While these techniques partially address the challenges of intracorporeal manipulation, they often require extensive duodenal mobilization, present complexities in tension control, may leave ischemic tissue ridges, or increase the risk of intra-abdominal contamination, particularly in patients with larger tumors or tumors close to the pylorus. Recent technological innovations have provided new solutions for totally laparoscopic circular stapling. Based on our team’s experience in laparoscopic total gastrectomy, we previously reported a technique combining a novel laparoscopic purse-string suture clamp (Lap-PSC) with a multi-functional sealing cap (MSC), successfully enabling safe and standardized application of circular stapler for gastroduodenal (Billroth I) and esophagojejunal anastomoses in a totally laparoscopic environment [ 12 , 13 ] . The core advantages of this system include stable instrument access with maintained pneumoperitoneum via the MSC and efficient, standardized purse-string suturing using the dedicated clamp, thereby circumventing traditional technical obstacles. Preliminary single-center retrospective studies demonstrated favorable short-term outcomes with low anastomosis-related complication rates, supporting its feasibility and safety . Beyond technical refinement, a deeper question arises: how can we move beyond mere technical feasibility comparisons to provide more precise, individualized decision-making based on patient biological responses? The perioperative systemic inflammatory response, as the core reaction to surgical trauma, offers a critical window into postoperative recovery and complication risk. Dynamic changes in key inflammatory markers such as interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and C-reactive protein (CRP) directly reflect the extent of surgical trauma, ischemia-reperfusion injury, and the early healing environment at the anastomotic site [ 14 , 15 ] . Excessive or prolonged inflammation is associated with anastomotic leakage, intra-abdominal infection, systemic inflammatory response syndrome, and prolonged hospitalization [ 16 ] . Theoretically, different surgical approaches (e.g., distal vs. total gastrectomy) inflict varying degrees of trauma, and different anastomotic techniques (e.g., end-to-end/end-to-side vs. side-to-side) may provoke distinct inflammatory responses due to differences in tissue perfusion, anastomotic tension, and local microenvironment. For instance, linear techniques often require more extensive duodenal mobilization, potentially increasing local tissue trauma and ischemic risk, which could trigger more pronounced local and systemic inflammation. Conversely, our modified circular stapling technique, with its more physiological reconstruction and better tension control, may induce a milder inflammatory response. However, prospective studies systematically comparing the impact of different surgical-anastomotic combinations (TLDG vs. LTG; CS vs. LS) on perioperative inflammatory trajectories and their correlation with clinical outcomes in totally laparoscopic gastric cancer surgery are lacking. Addressing this gap is essential for advancing gastric cancer surgery from a “technique-oriented” to a “biology-oriented” personalized decision-making paradigm. Therefore, this prospective cohort study aimed to continuously monitor perioperative inflammatory markers in gastric cancer patients and analyze their association with different surgical-anastomotic strategies. We hypothesized that the circular stapling technique assisted by Lap-PSC and MSC would induce a milder and faster-resolving systemic inflammatory response compared to conventional linear stapling, and that this favorable inflammatory profile would be associated with lower postoperative complication rates, particularly anastomosis-related events. Our findings may provide an objective biomarker-based dimension for surgeons in selecting the optimal surgical and anastomotic strategy, ultimately improving perioperative management and long-term outcomes. Methods 1. Study Design This prospective observational cohort study was designed to evaluate the association between perioperative systemic inflammatory responses and different laparoscopic gastric cancer surgical and anastomotic techniques. The study protocol adhered to the ethical principles of the Declaration of Helsinki and was approved by the Institutional Review Board of our hospital (Approval No.:2026-K-034). Clinical trial number: not applicable. Reporting followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines. This was a prospectively designed observational cohort study. The protocol was approved by the Institutional Review Board of our hospital (Approval No.: 2026-K-034). As the study involved only the secondary analysis of anonymized data generated from routine clinical practice without any additional patient burden or risk, the requirement for written informed consent was waived by the ethics committee. All data were handled in strict confidentiality. 2. Patient Enrollment and Grouping 2.1 Patient Source: Consecutive patients scheduled for elective radical laparoscopic gastrectomy at our Gastrointestinal Surgery Center between June 2023 and June 2025 were recruited. 2.2 Inclusion Criteria: Age 18–80 years. Primary gastric adenocarcinoma confirmed by preoperative endoscopic biopsy. Clinical stage (cTNM, AJCC 8th edition) cT1–4a, N0–2, M0, suitable for radical distal or total gastrectomy. American Society of Anesthesiologists (ASA) physical status I–III. Written informed consent obtained preoperatively. 2.3 Exclusion Criteria: Neoadjuvant chemotherapy or radiotherapy. Previous major upper abdominal surgery. Uncontrolled systemic infection, active autoimmune disease, or long-term use of immunosuppressants/corticosteroids. Severe organ dysfunction (e.g., cardiac, pulmonary, hepatic, renal failure). Emergency surgery or intraoperative finding of unresectable tumor (palliative surgery). Conversion to open surgery due to technical or safety reasons. 2.4 Grouping: Eligible patients were divided into four cohorts based on the surgical procedure and anastomotic technique: Group A (TLDG-CS): Totally laparoscopic distal gastrectomy (TLDG) with Billroth I gastroduodenal anastomosis using a circular stapler (with Lap-PSC and MSC). Group B (TLDG-LS): TLDG with intracorporeal linear stapled anastomosis (Delta or triangular technique). Group C (LTG-CS): Totally laparoscopic total gastrectomy (LTG) with Roux-en-Y esophagojejunal anastomosis using a circular stapler (with Lap-PSC and MSC). Group D (LTG-LS): LTG with intracorporeal linear stapled esophagojejunal anastomosis (Overlap or functional end-to-end anastomosis). All procedures were performed by the same surgical team with extensive experience in laparoscopic gastric surgery (>100 cases annually) to minimize inter-operator variability. 3. Surgical and Anastomotic Technique 3.1 General Surgical Protocol: All patients underwent general anesthesia in a modified French position. CO₂ pneumoperitoneum was established and maintained at 12–14 mmHg. A five-port (TLDG) or four-port (LTG) layout was used. 3.2 Group-Specific Techniques: Group A (TLDG-CS): After D1+ or D2 lymphadenectomy and mobilization of the duodenal bulb, a 5-cm auxiliary incision was made in the left subcostal region to place the MSC. The Lap-PSC was introduced through the MSC to perform a full-thickness purse-string suture on the duodenum, which was then transected. After gastric transection and specimen extraction, a 25-mm circular stapler was introduced through the MSC to perform a tension-free gastroduodenal anastomosis. Group C (LTG-CS): Following D2 lymphadenectomy and mobilization of the abdominal esophagus, a 5-cm upper midline auxiliary incision was made for MSC placement. The Lap-PSC was used for esophageal purse-string suturing. After esophageal transection, the anvil head was placed. A Roux-en-Y jejunal limb was prepared, and the circular stapler was introduced through the MSC and jejunal stump to complete an esophagojejunal end-to-side anastomosis. 4. Inflammatory Marker Measurement and Data Collection The clinical data and blood samples analyzed in this study were those routinely obtained during the perioperative period of standard totally laparoscopic gastrectomy for cancer. The research protocol did not alter any clinical decision-making or procedural workflows for data acquisition 4.1 Blood Sampling: Peripheral venous blood (5 mL) was collected at four time points: T0 (preoperative, before anesthesia induction), T1 (24 h postoperatively), T2 (72 h postoperatively), and T3 (postoperative day 7 or discharge day). Samples were centrifuged, and serum was stored at −80°C until analysis. 4.2 Inflammatory Marker Assays: Serum IL-6 and TNF-α levels were measured using commercial ELISA kits (R&D Systems, Minneapolis, MN, USA). hs-CRP was measured using an automated immunoturbidimetric assay (Roche cobas c 702). All assays were performed by laboratory personnel blinded to group allocation. 4.3 Clinical Data Collection: Baseline demographics, operative details (operative time, blood loss, lymph node yield), postoperative recovery milestones (first flatus, oral intake, hospital stay), and complications (graded by Clavien-Dindo classification) within 30 days were recorded. Anastomosis-related complications (leak, bleeding, stenosis) were diagnosed based on clinical, imaging, and/or endoscopic findings. 5. Sample Size Calculation Based on preliminary data, an expected mean difference of 30 pg/mL in IL-6 at T2 between TLDG-CS and TLDG-LS groups, with a pooled standard deviation of 40 pg/mL, was assumed. With α=0.05 (two-tailed) and power (1−β)=0.80, the minimum sample size per group was 45. Accounting for a lower proportion of LTG cases and possible dropout, a total sample size of 180 was targeted. 6. Statistical Analysis Data were analyzed using SPSS 28.0 (IBM Corp., Armonk, NY, USA) and R (version 4.2.0). Continuous variables were expressed as mean ± SD or median (IQR) and compared using t-test, Mann–Whitney U test, or ANOVA. Categorical variables were expressed as n (%) and compared using chi-square or Fisher’s exact test. Inflammatory marker dynamics were analyzed using repeated-measures ANOVA. Multivariate linear regression was used to identify independent predictors of inflammatory marker levels. Logistic regression was used to analyze risk factors for complications. A two-sided p<0.05 was considered statistically significant. Results 1. Patient Enrollment and Baseline Characteristics Of 215 screened patients, 35 were excluded (16 received neoadjuvant therapy, 11 had unresectable disease, 8 converted to open surgery). Finally, 180 patients were enrolled (overall inclusion rate: 83.7%) and allocated to four groups: TLDG-CS (n = 50), TLDG-LS (n = 50), LTG-CS (n = 40), LTG-LS (n = 40). No intraoperative mortality occurred. Baseline demographics, comorbidities, and clinical stage were comparable across groups (all p > 0.05, Table 1 ). Table 1 Baseline demographic and preoperative clinical characteristics Variable TLDG-CS (n = 50) TLDG-LS (n = 50) LTG-CS (n = 40) LTG-LS (n = 40) p-value Demographics Age (years), mean ± SD 62.3 ± 8.1 63.7 ± 7.5 64.2 ± 9.0 63.0 ± 8.3 0.724 Male, n (%) 34 (68.0) 32 (64.0) 28 (70.0) 26 (65.0) 0.932 BMI (kg/m²), mean ± SD 23.5 ± 3.2 24.0 ± 3.5 22.8 ± 3.0 23.6 ± 3.4 0.356 ASA grade (I/II/III), n 8/35/7 10/33/7 6/28/6 7/27/6 0.891 Comorbidities, n (%) Hypertension 15 (30.0) 17 (34.0) 12 (30.0) 14 (35.0) 0.951 Diabetes 8 (16.0) 7 (14.0) 6 (15.0) 5 (12.5) 0.983 Preoperative nutrition Albumin (g/L), mean ± SD 38.5 ± 4.1 39.1 ± 3.8 37.8 ± 4.5 38.3 ± 4.0 0.568 Prealbumin (mg/L), mean ± SD 225 ± 52 231 ± 48 218 ± 55 227 ± 50 0.642 Clinical stage (cTNM), n 0.876 I 22 20 15 13 II 18 19 14 15 III 10 11 11 12 2. Surgical and Pathological Outcomes LTG groups had longer operative times and greater blood loss than TLDG groups (p < 0.001). Within the same surgical type, CS groups had shorter operative times than LS groups, reaching significance for TLDG-CS vs. TLDG-LS (148.3 ± 21.5 vs. 172.8 ± 28.4 min, p = 0.003). Lymph node yield and R0 resection rates were similar across groups. Pathological stage, tumor size, histology, and lymphovascular invasion were comparable (all p > 0.05, Table 2 ). Table 2 Surgical outcomes and pathological findings Variable TLDG-CS (n = 50) TLDG-LS (n = 50) LTG-CS (n = 40) LTG-LS (n = 40) p-value Operative outcomes Operative time (min), mean ± SD 148.3 ± 21.5*a* 172.8 ± 28.4 242.6 ± 35.1*b* 268.9 ± 40.7 < 0.001* Blood loss (ml), median (IQR) 80 (50–120)*a* 100 (70–150) 150 (100–200)*b* 180 (130–250) < 0.001* Lymph nodes harvested, median (IQR) 32 (26–38) 30 (25–37) 35 (29–42) 33 (27–40) 0.215 Pathological findings Tumor size (cm), mean ± SD 3.2 ± 1.5 3.5 ± 1.7 4.0 ± 2.1 4.3 ± 2.3 0.102 pT stage, n 0.788 T1 18 16 10 8 T2 15 14 12 10 T3 12 14 11 14 T4a 5 6 7 8 pN stage, n 0.845 N0 28 26 18 16 N1 12 13 11 12 N2 7 8 8 9 N3 3 3 3 3 pTNM stage, n 0.912 I 25 23 15 14 II 16 18 14 15 III 9 9 11 11 Lymphovascular invasion, n (%) 12 (24.0) 14 (28.0) 13 (32.5) 15 (37.5) 0.534 Perineural invasion, n (%) 10 (20.0) 11 (22.0) 12 (30.0) 14 (35.0) 0.329 *Note: *a* p < 0.05 vs. TLDG-LS; *b* p < 0.05 vs. LTG-LS; * overall p < 0.001.* 3. Perioperative Inflammatory Marker Dynamics Repeated-measures ANOVA showed significant main effects of time and group, and significant time × group interactions for IL-6, TNF-α, and hs-CRP (all p < 0.01). Levels peaked at T1 and declined thereafter. At T2, IL-6 and hs-CRP levels were significantly lower in CS groups compared to LS groups for both TLDG and LTG (e.g., TLDG-CS vs. TLDG-LS IL-6: 82.4 ± 28.1 vs. 115.6 ± 35.7 pg/mL, p < 0.001). Multivariate linear regression confirmed LS as an independent predictor of higher IL-6 (β = 28.4, 95%CI: 15.7–41.1) and hs-CRP (β = 12.3, 95%CI: 6.8–17.8) at T2 (both p < 0.001). LTG was also an independent predictor of stronger inflammatory responses. 4. Postoperative Recovery and Complications TLDG-CS group had significantly earlier first flatus, earlier liquid diet initiation, and shorter hospital stay compared to TLDG-LS (all p < 0.05). The overall anastomosis-related complication rate was lower in the combined CS groups (3.3%, 3/90) than in the LS groups (8.9%, 8/90, p = 0.048). Other complication rates did not differ significantly. No postoperative mortality occurred (Table 3 ). Table 3 Postoperative recovery and complication profiles Variable TLDG-CS (n = 50) TLDG-LS (n = 50) LTG-CS (n = 40) LTG-LS (n = 40) p-value Recovery indicators First flatus (days), mean ± SD 2.8 ± 0.7*a* 3.3 ± 0.9 3.5 ± 1.0 3.7 ± 1.1 0.001* Liquid diet start (days), mean ± SD 4.1 ± 1.1*a* 4.8 ± 1.4 5.2 ± 1.5 5.5 ± 1.6 0.002* Postoperative stay (days), median (IQR) 7 (6–9)*a* 8 (7–11) 10 (9–13) 11 (10–14) < 0.001* Total complications (C-D ≥ II), n (%) 8 (16.0) 11 (22.0) 9 (22.5) 10 (25.0) 0.689 Anastomosis-related complications, n (%) 1 (2.0) 3 (6.0) 1 (2.5) 5 (12.5) 0.048* - Leak 0 2 1 2 - Bleeding 1 1 0 2 - Stenosis 0 0 0 1 Other major complications, n (%) Pneumonia 2 (4.0) 3 (6.0) 2 (5.0) 3 (7.5) 0.912 Intra-abdominal infection 1 (2.0) 2 (4.0) 2 (5.0) 1 (2.5) 0.843 Delayed gastric emptying 3 (6.0) 3 (6.0) 2 (5.0) 1 (2.5) 0.879 Chyle leak 1 (2.0) 0 1 (2.5) 0 0.542 *Note: *a* p < 0.05 vs. TLDG-LS group. C-D: Clavien-Dindo classification.* Discussion This prospective cohort study is the first to systematically compare the perioperative inflammatory trajectories and clinical outcomes between circular stapling (assisted by Lap-PSC and MSC) and linear stapling techniques in totally laparoscopic distal and total gastrectomy for gastric cancer. Our findings demonstrate that: (1) the circular stapling technique is feasible and shortens operative time; (2) it induces a milder and faster-resolving systemic inflammatory response compared to linear stapling, especially evident at 72 hours postoperatively; and (3) this attenuated inflammatory profile is associated with a lower anastomosis-related complication rate. The operative efficiency of circular stapling with Lap-PSC/MSC is notable, reducing TLDG operative time by approximately 25 minutes. This efficiency stems from the simplified, standardized technique that replicates open surgical principles laparoscopically [ 12 , 13 ] . More importantly, our study provides biological evidence supporting circular stapling. Lower IL-6 and hs-CRP levels in CS groups may be attributed to more physiological reconstruction, less tissue trauma, better blood supply preservation, and more stable operative workflow [ 17 , 18 ] . Multivariate analysis confirmed anastomotic technique as an independent predictor of inflammatory intensity [ 19 , 20 ] . The clinical correlation—lower anastomosis-related complications in CS groups—aligns with the concept that excessive inflammation impairs healing [ 21 ] . Although overall complications were similar, the reduction in anastomotic events is clinically meaningful. Limitations include the non-randomized design, single-center setting, and focus on short-term outcomes. Future multi-center randomized trials with long-term oncological and quality-of-life endpoints are warranted. Conclusion In totally laparoscopic gastric cancer surgery, circular stapling assisted by Lap-PSC and MSC significantly attenuates postoperative systemic inflammation and is associated with lower anastomotic complication rates compared to linear stapling. Perioperative inflammatory monitoring may offer an objective biomarker-based tool for personalized surgical strategy selection, promoting precision in gastric cancer surgery. Declarations Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution Z.W. (Zhiqiang Wang) conceived and designed the study, performed data curation and statistical analysis, and wrote the original draft of the manuscript. Z.G. (Zhiyuan Guo) contributed to surgical procedures, patient enrollment, and clinical data collection. J.T. (Jian Tang) assisted in laboratory assays and inflammatory marker detection. L.Z. 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Cite Share Download PDF Status: Published Journal Publication published 06 Apr, 2026 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 23 Feb, 2026 Reviews received at journal 19 Feb, 2026 Reviews received at journal 16 Feb, 2026 Reviewers agreed at journal 11 Feb, 2026 Reviews received at journal 10 Feb, 2026 Reviewers agreed at journal 10 Feb, 2026 Reviews received at journal 10 Feb, 2026 Reviewers agreed at journal 10 Feb, 2026 Reviewers agreed at journal 10 Feb, 2026 Reviewers invited by journal 09 Feb, 2026 Editor assigned by journal 05 Feb, 2026 Submission checks completed at journal 05 Feb, 2026 First submitted to journal 20 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8645414\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":589675415,\"identity\":\"f37ec023-1b9c-4797-b0f5-13ae4e0d1f5d\",\"order_by\":0,\"name\":\"zhiqiang wang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Graduate School of Dalian Medical University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"zhiqiang\",\"middleName\":\"\",\"lastName\":\"wang\",\"suffix\":\"\"},{\"id\":589675416,\"identity\":\"80af0f22-28f9-4685-b0ec-1f9087992070\",\"order_by\":1,\"name\":\"jian Tang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The Yancheng Clinical College of Xuzhou Medical University \\u0026 The First People’s Hospital of Yancheng\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"jian\",\"middleName\":\"\",\"lastName\":\"Tang\",\"suffix\":\"\"},{\"id\":589675417,\"identity\":\"e05c8359-b26c-4047-8bd4-5768ab3dcf85\",\"order_by\":2,\"name\":\"qiuyue she\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The Yancheng Clinical College of Xuzhou Medical University \\u0026 The First People’s Hospital of Yancheng\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"qiuyue\",\"middleName\":\"\",\"lastName\":\"she\",\"suffix\":\"\"},{\"id\":589675418,\"identity\":\"847bcb8c-d3be-42f0-b446-1d2ef302f9b1\",\"order_by\":3,\"name\":\"zhiyuan guo\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The Yancheng Clinical College of Xuzhou Medical University \\u0026 The First People’s Hospital of Yancheng\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"zhiyuan\",\"middleName\":\"\",\"lastName\":\"guo\",\"suffix\":\"\"},{\"id\":589675419,\"identity\":\"99b269a0-f74e-4ef8-870f-81c8be5c98f3\",\"order_by\":4,\"name\":\"linsen zhou\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The Yancheng Clinical College of Xuzhou Medical University \\u0026 The First People’s Hospital of Yancheng\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"linsen\",\"middleName\":\"\",\"lastName\":\"zhou\",\"suffix\":\"\"},{\"id\":589675420,\"identity\":\"7f137a62-0b34-4b56-87a3-7d543696f802\",\"order_by\":5,\"name\":\"Haohai Jiang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The Yancheng Clinical College of Xuzhou Medical University \\u0026 The First People’s Hospital of Yancheng\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Haohai\",\"middleName\":\"\",\"lastName\":\"Jiang\",\"suffix\":\"\"},{\"id\":589675421,\"identity\":\"235fa216-af76-4153-bab2-2ee4555e4066\",\"order_by\":6,\"name\":\"jianming zhang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The Yancheng Clinical College of Xuzhou Medical University \\u0026 The First People’s Hospital of Yancheng\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"jianming\",\"middleName\":\"\",\"lastName\":\"zhang\",\"suffix\":\"\"},{\"id\":589675422,\"identity\":\"230d802f-d4a9-4990-9992-33a1c3fcaa09\",\"order_by\":7,\"name\":\"liming tang\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYDCCA2DSgoeBGUh9MLCxI0ILSCmDBFgL44yCtGSitYDZzDwfDjE2ENLBd/v8wc8FvyRkdNt5D7+2MQCawH746AZ8WiTPJTNLz+yT4DE7zJdmnWNwh4+BJy3tBj4tBmeYGaR5e0BaeMyMcwyeMQP9ZUZIC/NvuBYLg8OMDURoYZPm+QHWYvyYgRgtkmeYzax5GyC2MPYYpCWzEfIL3xnGx7d5/tjYm50/Y/zhxx8bO372w8fwagEDxjYwxQaOHTaCysHgD5hk/kCc6lEwCkbBKBhpAABeG0QOGzPzegAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"Graduate School of Dalian Medical University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"liming\",\"middleName\":\"\",\"lastName\":\"tang\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-01-20 05:56:50\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8645414/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8645414/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s12893-026-03711-8\",\"type\":\"published\",\"date\":\"2026-04-06T15:58:04+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":106808857,\"identity\":\"382d52bb-9abf-4407-8577-27cc36fb636e\",\"added_by\":\"auto\",\"created_at\":\"2026-04-13 16:03:53\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1057011,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8645414/v1/d3022ffe-b379-42e9-8124-5d294018a2d2.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Optimization of Anastomotic Strategy in Totally Laparoscopic Gastric Cancer Surgery Based on Dynamic Inflammatory Response Trajectories: A Prospective Cohort Study\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eGastric cancer remains one of the most common and lethal malignancies worldwide. According to GLOBOCAN 2022, it ranks as the fifth most common cancer and the fifth leading cause of cancer-related mortality, with nearly one million new cases and over 650,000 deaths annually. In China, despite a declining incidence, the disease burden remains substantial, with 358,700 new cases and 260,400 deaths reported in 2022, ranking fifth in incidence and third in mortality among all cancers \\u003csup\\u003e[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]\\u003c/sup\\u003e. Surgical resection remains the cornerstone of curative treatment, and the introduction of laparoscopic techniques has revolutionized its practice. Since the first report of laparoscopic-assisted distal gastrectomy by Kitano et al. in 1994, several high-quality randomized controlled trials\\u0026mdash;including the Japanese JCOG0912, Korean KLASS-01, and Chinese CLASS-01 studies\\u0026mdash;have established the non-inferiority, and in some perioperative outcomes, superiority of laparoscopic distal gastrectomy over open surgery for early and locally advanced gastric cancer \\u003csup\\u003e[\\u003cspan additionalcitationids=\\\"CR4 CR5\\\" citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eWithin the framework of laparoscopic gastric surgery, the choice of digestive reconstruction method, particularly the anastomotic technique, critically influences postoperative functional recovery and complication rates. Circular stapler (CS) and linear stapler (LS) anastomoses are the two main techniques, each with theoretical advantages and clinical challenges. CS anastomosis, considered the \\u0026ldquo;gold standard\\u0026rdquo; in the open surgery era, is known for creating stable-caliber, well-vascularized end-to-end or end-to-side anastomoses \\u003csup\\u003e[\\u003cspan additionalcitationids=\\\"CR8\\\" citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]\\u003c/sup\\u003e. However, performing precise purse-string sutures in a totally laparoscopic setting has long been a technical bottleneck. Consequently, several intracorporeal linear anastomotic techniques\\u0026mdash;such as Delta anastomosis, triangular stapling technique (TST), self-pulling and latter transection Delta anastomosis (Delta SPLT), and the Billroth I anastomosis with rectangular transection (Billroth I-ART)\\u0026mdash;have been developed to facilitate laparoscopic reconstruction \\u003csup\\u003e[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]\\u003c/sup\\u003e. While these techniques partially address the challenges of intracorporeal manipulation, they often require extensive duodenal mobilization, present complexities in tension control, may leave ischemic tissue ridges, or increase the risk of intra-abdominal contamination, particularly in patients with larger tumors or tumors close to the pylorus.\\u003c/p\\u003e \\u003cp\\u003eRecent technological innovations have provided new solutions for totally laparoscopic circular stapling. Based on our team\\u0026rsquo;s experience in laparoscopic total gastrectomy, we previously reported a technique combining a novel laparoscopic purse-string suture clamp (Lap-PSC) with a multi-functional sealing cap (MSC), successfully enabling safe and standardized application of circular stapler for gastroduodenal (Billroth I) and esophagojejunal anastomoses in a totally laparoscopic environment \\u003csup\\u003e[\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]\\u003c/sup\\u003e. The core advantages of this system include stable instrument access with maintained pneumoperitoneum via the MSC and efficient, standardized purse-string suturing using the dedicated clamp, thereby circumventing traditional technical obstacles. Preliminary single-center retrospective studies demonstrated favorable short-term outcomes with low anastomosis-related complication rates, supporting its feasibility and safety .\\u003c/p\\u003e \\u003cp\\u003eBeyond technical refinement, a deeper question arises: how can we move beyond mere technical feasibility comparisons to provide more precise, individualized decision-making based on patient biological responses? The perioperative systemic inflammatory response, as the core reaction to surgical trauma, offers a critical window into postoperative recovery and complication risk. Dynamic changes in key inflammatory markers such as interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and C-reactive protein (CRP) directly reflect the extent of surgical trauma, ischemia-reperfusion injury, and the early healing environment at the anastomotic site \\u003csup\\u003e[\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]\\u003c/sup\\u003e. Excessive or prolonged inflammation is associated with anastomotic leakage, intra-abdominal infection, systemic inflammatory response syndrome, and prolonged hospitalization \\u003csup\\u003e[\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e]\\u003c/sup\\u003e. Theoretically, different surgical approaches (e.g., distal vs. total gastrectomy) inflict varying degrees of trauma, and different anastomotic techniques (e.g., end-to-end/end-to-side vs. side-to-side) may provoke distinct inflammatory responses due to differences in tissue perfusion, anastomotic tension, and local microenvironment. For instance, linear techniques often require more extensive duodenal mobilization, potentially increasing local tissue trauma and ischemic risk, which could trigger more pronounced local and systemic inflammation. Conversely, our modified circular stapling technique, with its more physiological reconstruction and better tension control, may induce a milder inflammatory response.\\u003c/p\\u003e \\u003cp\\u003eHowever, prospective studies systematically comparing the impact of different surgical-anastomotic combinations (TLDG vs. LTG; CS vs. LS) on perioperative inflammatory trajectories and their correlation with clinical outcomes in totally laparoscopic gastric cancer surgery are lacking. Addressing this gap is essential for advancing gastric cancer surgery from a \\u0026ldquo;technique-oriented\\u0026rdquo; to a \\u0026ldquo;biology-oriented\\u0026rdquo; personalized decision-making paradigm.\\u003c/p\\u003e \\u003cp\\u003eTherefore, this prospective cohort study aimed to continuously monitor perioperative inflammatory markers in gastric cancer patients and analyze their association with different surgical-anastomotic strategies. We hypothesized that the circular stapling technique assisted by Lap-PSC and MSC would induce a milder and faster-resolving systemic inflammatory response compared to conventional linear stapling, and that this favorable inflammatory profile would be associated with lower postoperative complication rates, particularly anastomosis-related events. Our findings may provide an objective biomarker-based dimension for surgeons in selecting the optimal surgical and anastomotic strategy, ultimately improving perioperative management and long-term outcomes.\\u003c/p\\u003e \"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003e1. Study Design\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis prospective observational cohort study was designed to evaluate the association between perioperative systemic inflammatory responses and different laparoscopic gastric cancer surgical and anastomotic techniques. The study protocol adhered to the ethical principles of the Declaration of Helsinki and was approved by the Institutional Review Board of our hospital (Approval No.:2026-K-034). \\u003cstrong\\u003eClinical trial number: not applicable.\\u003c/strong\\u003e Reporting followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.\\u003c/p\\u003e\\n\\u003cp\\u003eThis was a prospectively designed observational cohort study. The protocol was approved by the Institutional Review Board of our hospital (Approval No.: 2026-K-034). As the study involved only the secondary analysis of anonymized data generated from routine clinical practice without any additional patient burden or risk, the requirement for written informed consent was waived by the ethics committee. All data were handled in strict confidentiality.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e2. Patient Enrollment and Grouping\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e2.1 Patient Source:\\u003c/strong\\u003e Consecutive patients scheduled for elective radical laparoscopic gastrectomy at our Gastrointestinal Surgery Center between June 2023 and June 2025 were recruited.\\u003cbr\\u003e\\u003cstrong\\u003e2.2 Inclusion Criteria:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cul type=\\\"disc\\\"\\u003e\\n \\u003cli\\u003eAge 18–80 years.\\u003c/li\\u003e\\n \\u003cli\\u003ePrimary gastric adenocarcinoma confirmed by preoperative endoscopic biopsy.\\u003c/li\\u003e\\n \\u003cli\\u003eClinical stage (cTNM, AJCC 8th edition) cT1–4a, N0–2, M0, suitable for radical distal or total gastrectomy.\\u003c/li\\u003e\\n \\u003cli\\u003eAmerican Society of Anesthesiologists (ASA) physical status I–III.\\u003c/li\\u003e\\n \\u003cli\\u003eWritten informed consent obtained preoperatively.\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e2.3 Exclusion Criteria:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cul type=\\\"disc\\\"\\u003e\\n \\u003cli\\u003eNeoadjuvant chemotherapy or radiotherapy.\\u003c/li\\u003e\\n \\u003cli\\u003ePrevious major upper abdominal surgery.\\u003c/li\\u003e\\n \\u003cli\\u003eUncontrolled systemic infection, active autoimmune disease, or long-term use of immunosuppressants/corticosteroids.\\u003c/li\\u003e\\n \\u003cli\\u003eSevere organ dysfunction (e.g., cardiac, pulmonary, hepatic, renal failure).\\u003c/li\\u003e\\n \\u003cli\\u003eEmergency surgery or intraoperative finding of unresectable tumor (palliative surgery).\\u003c/li\\u003e\\n \\u003cli\\u003eConversion to open surgery due to technical or safety reasons.\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e2.4 Grouping:\\u003c/strong\\u003e Eligible patients were divided into four cohorts based on the surgical procedure and anastomotic technique:\\u003c/p\\u003e\\n\\u003cul type=\\\"disc\\\"\\u003e\\n \\u003cli\\u003eGroup A (TLDG-CS): Totally laparoscopic distal gastrectomy (TLDG) with Billroth I gastroduodenal anastomosis using a circular stapler (with Lap-PSC and MSC).\\u003c/li\\u003e\\n \\u003cli\\u003eGroup B (TLDG-LS): TLDG with intracorporeal linear stapled anastomosis (Delta or triangular technique).\\u003c/li\\u003e\\n \\u003cli\\u003eGroup C (LTG-CS): Totally laparoscopic total gastrectomy (LTG) with Roux-en-Y esophagojejunal anastomosis using a circular stapler (with Lap-PSC and MSC).\\u003c/li\\u003e\\n \\u003cli\\u003eGroup D (LTG-LS): LTG with intracorporeal linear stapled esophagojejunal anastomosis (Overlap or functional end-to-end anastomosis).\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eAll procedures were performed by the same surgical team with extensive experience in laparoscopic gastric surgery (\\u0026gt;100 cases annually) to minimize inter-operator variability.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e3. Surgical and Anastomotic Technique\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e3.1 General Surgical Protocol:\\u003c/strong\\u003e All patients underwent general anesthesia in a modified French position. CO₂ pneumoperitoneum was established and maintained at 12–14 mmHg. A five-port (TLDG) or four-port (LTG) layout was used.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e3.2 Group-Specific Techniques:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cul type=\\\"disc\\\"\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003eGroup A (TLDG-CS):\\u003c/strong\\u003e After D1+ or D2 lymphadenectomy and mobilization of the duodenal bulb, a 5-cm auxiliary incision was made in the left subcostal region to place the MSC. The Lap-PSC was introduced through the MSC to perform a full-thickness purse-string suture on the duodenum, which was then transected. After gastric transection and specimen extraction, a 25-mm circular stapler was introduced through the MSC to perform a tension-free gastroduodenal anastomosis.\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003eGroup C (LTG-CS):\\u003c/strong\\u003e Following D2 lymphadenectomy and mobilization of the abdominal esophagus, a 5-cm upper midline auxiliary incision was made for MSC placement. The Lap-PSC was used for esophageal purse-string suturing. After esophageal transection, the anvil head was placed. A Roux-en-Y jejunal limb was prepared, and the circular stapler was introduced through the MSC and jejunal stump to complete an esophagojejunal end-to-side anastomosis.\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e4. Inflammatory Marker Measurement and Data Collection\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe clinical data and blood samples analyzed in this study were those routinely obtained during the perioperative period of standard totally laparoscopic gastrectomy for cancer. The research protocol did not alter any clinical decision-making or procedural workflows for data acquisition\\u003cbr\\u003e\\u003cstrong\\u003e4.1 Blood Sampling:\\u003c/strong\\u003e Peripheral venous blood (5 mL) was collected at four time points: T0 (preoperative, before anesthesia induction), T1 (24 h postoperatively), T2 (72 h postoperatively), and T3 (postoperative day 7 or discharge day). Samples were centrifuged, and serum was stored at −80°C until analysis.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e4.2 Inflammatory Marker Assays:\\u003c/strong\\u003e Serum IL-6 and TNF-α levels were measured using commercial ELISA kits (R\\u0026amp;D Systems, Minneapolis, MN, USA). hs-CRP was measured using an automated immunoturbidimetric assay (Roche cobas c 702). All assays were performed by laboratory personnel blinded to group allocation.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e4.3 Clinical Data Collection:\\u003c/strong\\u003e Baseline demographics, operative details (operative time, blood loss, lymph node yield), postoperative recovery milestones (first flatus, oral intake, hospital stay), and complications (graded by Clavien-Dindo classification) within 30 days were recorded. Anastomosis-related complications (leak, bleeding, stenosis) were diagnosed based on clinical, imaging, and/or endoscopic findings.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e5. Sample Size Calculation\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eBased on preliminary data, an expected mean difference of 30 pg/mL in IL-6 at T2 between TLDG-CS and TLDG-LS groups, with a pooled standard deviation of 40 pg/mL, was assumed. With α=0.05 (two-tailed) and power (1−β)=0.80, the minimum sample size per group was 45. Accounting for a lower proportion of LTG cases and possible dropout, a total sample size of 180 was targeted.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e6. Statistical Analysis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eData were analyzed using SPSS 28.0 (IBM Corp., Armonk, NY, USA) and R (version 4.2.0). Continuous variables were expressed as mean ± SD or median (IQR) and compared using t-test, Mann–Whitney U test, or ANOVA. Categorical variables were expressed as n (%) and compared using chi-square or Fisher’s exact test. Inflammatory marker dynamics were analyzed using repeated-measures ANOVA. Multivariate linear regression was used to identify independent predictors of inflammatory marker levels. Logistic regression was used to analyze risk factors for complications. A two-sided p\\u0026lt;0.05 was considered statistically significant.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\n\\u003ch3\\u003e1. Patient Enrollment and Baseline Characteristics\\u003c/h3\\u003e\\n\\u003cp\\u003eOf 215 screened patients, 35 were excluded (16 received neoadjuvant therapy, 11 had unresectable disease, 8 converted to open surgery). Finally, 180 patients were enrolled (overall inclusion rate: 83.7%) and allocated to four groups: TLDG-CS (n\\u0026thinsp;=\\u0026thinsp;50), TLDG-LS (n\\u0026thinsp;=\\u0026thinsp;50), LTG-CS (n\\u0026thinsp;=\\u0026thinsp;40), LTG-LS (n\\u0026thinsp;=\\u0026thinsp;40). No intraoperative mortality occurred. Baseline demographics, comorbidities, and clinical stage were comparable across groups (all p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05, Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eBaseline demographic and preoperative clinical characteristics\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"6\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariable\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTLDG-CS (n\\u0026thinsp;=\\u0026thinsp;50)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eTLDG-LS (n\\u0026thinsp;=\\u0026thinsp;50)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eLTG-CS (n\\u0026thinsp;=\\u0026thinsp;40)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eLTG-LS (n\\u0026thinsp;=\\u0026thinsp;40)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eDemographics\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAge (years), mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e62.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;8.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e63.7\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;7.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e64.2\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;9.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e63.0\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;8.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.724\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMale, n (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e34 (68.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e32 (64.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e28 (70.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e26 (65.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.932\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBMI (kg/m\\u0026sup2;), mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e23.5\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e24.0\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e22.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e23.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.356\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eASA grade (I/II/III), n\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8/35/7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e10/33/7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e6/28/6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e7/27/6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.891\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eComorbidities, n (%)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHypertension\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e15 (30.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e17 (34.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e12 (30.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e14 (35.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.951\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDiabetes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8 (16.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7 (14.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e6 (15.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e5 (12.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.983\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003ePreoperative nutrition\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAlbumin (g/L), mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e38.5\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e39.1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e37.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e38.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.568\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePrealbumin (mg/L), mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e225\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;52\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e231\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;48\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e218\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;55\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e227\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;50\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.642\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eClinical stage (cTNM), n\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.876\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eI\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e22\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e20\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eII\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e19\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIII\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e\\n\\u003ch3\\u003e2. Surgical and Pathological Outcomes\\u003c/h3\\u003e\\n\\u003cp\\u003eLTG groups had longer operative times and greater blood loss than TLDG groups (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Within the same surgical type, CS groups had shorter operative times than LS groups, reaching significance for TLDG-CS vs. TLDG-LS (148.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;21.5 vs. 172.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;28.4 min, p\\u0026thinsp;=\\u0026thinsp;0.003). Lymph node yield and R0 resection rates were similar across groups. Pathological stage, tumor size, histology, and lymphovascular invasion were comparable (all p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05, Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eSurgical outcomes and pathological findings\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"6\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariable\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTLDG-CS (n\\u0026thinsp;=\\u0026thinsp;50)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eTLDG-LS (n\\u0026thinsp;=\\u0026thinsp;50)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eLTG-CS (n\\u0026thinsp;=\\u0026thinsp;40)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eLTG-LS (n\\u0026thinsp;=\\u0026thinsp;40)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eOperative outcomes\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOperative time (min), mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e148.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;21.5*a*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e172.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;28.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e242.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;35.1*b*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e268.9\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;40.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001*\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBlood loss (ml), median (IQR)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e80 (50\\u0026ndash;120)*a*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e100 (70\\u0026ndash;150)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e150 (100\\u0026ndash;200)*b*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e180 (130\\u0026ndash;250)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001*\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLymph nodes harvested, median (IQR)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e32 (26\\u0026ndash;38)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e30 (25\\u0026ndash;37)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e35 (29\\u0026ndash;42)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e33 (27\\u0026ndash;40)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.215\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003ePathological findings\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTumor size (cm), mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3.2\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3.5\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4.0\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e4.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.102\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003epT stage, n\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.788\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eT1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eT2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eT3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eT4a\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003epN stage, n\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.845\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eN0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e28\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e26\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eN1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eN2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eN3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003epTNM stage, n\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.912\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eI\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e25\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e23\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eII\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIII\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLymphovascular invasion, n (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e12 (24.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e14 (28.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e13 (32.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e15 (37.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.534\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePerineural invasion, n (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10 (20.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e11 (22.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e12 (30.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e14 (35.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.329\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"6\\\"\\u003e*Note: *a* p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05 vs. TLDG-LS; *b* p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05 vs. LTG-LS; * overall p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001.*\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e\\n\\u003ch3\\u003e3. Perioperative Inflammatory Marker Dynamics\\u003c/h3\\u003e\\n\\u003cp\\u003eRepeated-measures ANOVA showed significant main effects of time and group, and significant time \\u0026times; group interactions for IL-6, TNF-α, and hs-CRP (all p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01). Levels peaked at T1 and declined thereafter. At T2, IL-6 and hs-CRP levels were significantly lower in CS groups compared to LS groups for both TLDG and LTG (e.g., TLDG-CS vs. TLDG-LS IL-6: 82.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;28.1 vs. 115.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;35.7 pg/mL, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Multivariate linear regression confirmed LS as an independent predictor of higher IL-6 (β\\u0026thinsp;=\\u0026thinsp;28.4, 95%CI: 15.7\\u0026ndash;41.1) and hs-CRP (β\\u0026thinsp;=\\u0026thinsp;12.3, 95%CI: 6.8\\u0026ndash;17.8) at T2 (both p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). LTG was also an independent predictor of stronger inflammatory responses.\\u003c/p\\u003e\\n\\u003ch3\\u003e4. Postoperative Recovery and Complications\\u003c/h3\\u003e\\n\\u003cp\\u003eTLDG-CS group had significantly earlier first flatus, earlier liquid diet initiation, and shorter hospital stay compared to TLDG-LS (all p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05). The overall anastomosis-related complication rate was lower in the combined CS groups (3.3%, 3/90) than in the LS groups (8.9%, 8/90, p\\u0026thinsp;=\\u0026thinsp;0.048). Other complication rates did not differ significantly. No postoperative mortality occurred (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003ePostoperative recovery and complication profiles\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"6\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariable\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTLDG-CS (n\\u0026thinsp;=\\u0026thinsp;50)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eTLDG-LS (n\\u0026thinsp;=\\u0026thinsp;50)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eLTG-CS (n\\u0026thinsp;=\\u0026thinsp;40)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eLTG-LS (n\\u0026thinsp;=\\u0026thinsp;40)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eRecovery indicators\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFirst flatus (days), mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.7*a*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3.5\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.7\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.001*\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLiquid diet start (days), mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4.1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.1*a*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e5.2\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e5.5\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.002*\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostoperative stay (days), median (IQR)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7 (6\\u0026ndash;9)*a*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8 (7\\u0026ndash;11)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e10 (9\\u0026ndash;13)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e11 (10\\u0026ndash;14)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001*\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eTotal complications (C-D\\u0026thinsp;\\u0026ge;\\u0026thinsp;II), n (%)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8 (16.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e11 (22.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e9 (22.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e10 (25.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.689\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eAnastomosis-related complications, n (%)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (2.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3 (6.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1 (2.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e5 (12.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.048*\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e- Leak\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e- Bleeding\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e- Stenosis\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eOther major complications, n (%)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePneumonia\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2 (4.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3 (6.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2 (5.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3 (7.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.912\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIntra-abdominal infection\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (2.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2 (4.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2 (5.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1 (2.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.843\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDelayed gastric emptying\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3 (6.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3 (6.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2 (5.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1 (2.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.879\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eChyle leak\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (2.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1 (2.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.542\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"6\\\"\\u003e*Note: *a* p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05 vs. TLDG-LS group. C-D: Clavien-Dindo classification.*\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis prospective cohort study is the first to systematically compare the perioperative inflammatory trajectories and clinical outcomes between circular stapling (assisted by Lap-PSC and MSC) and linear stapling techniques in totally laparoscopic distal and total gastrectomy for gastric cancer. Our findings demonstrate that: (1) the circular stapling technique is feasible and shortens operative time; (2) it induces a milder and faster-resolving systemic inflammatory response compared to linear stapling, especially evident at 72 hours postoperatively; and (3) this attenuated inflammatory profile is associated with a lower anastomosis-related complication rate.\\u003c/p\\u003e \\u003cp\\u003eThe operative efficiency of circular stapling with Lap-PSC/MSC is notable, reducing TLDG operative time by approximately 25 minutes. This efficiency stems from the simplified, standardized technique that replicates open surgical principles laparoscopically \\u003csup\\u003e[\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eMore importantly, our study provides biological evidence supporting circular stapling. Lower IL-6 and hs-CRP levels in CS groups may be attributed to more physiological reconstruction, less tissue trauma, better blood supply preservation, and more stable operative workflow \\u003csup\\u003e[\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]\\u003c/sup\\u003e. Multivariate analysis confirmed anastomotic technique as an independent predictor of inflammatory intensity \\u003csup\\u003e[\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e]\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThe clinical correlation\\u0026mdash;lower anastomosis-related complications in CS groups\\u0026mdash;aligns with the concept that excessive inflammation impairs healing \\u003csup\\u003e[\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e]\\u003c/sup\\u003e. Although overall complications were similar, the reduction in anastomotic events is clinically meaningful.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eLimitations\\u003c/b\\u003e include the non-randomized design, single-center setting, and focus on short-term outcomes. Future multi-center randomized trials with long-term oncological and quality-of-life endpoints are warranted.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eIn totally laparoscopic gastric cancer surgery, circular stapling assisted by Lap-PSC and MSC significantly attenuates postoperative systemic inflammation and is associated with lower anastomotic complication rates compared to linear stapling. Perioperative inflammatory monitoring may offer an objective biomarker-based tool for personalized surgical strategy selection, promoting precision in gastric cancer surgery.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003eFunding\\u003c/h2\\u003e \\u003cp\\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eZ.W. (Zhiqiang Wang) conceived and designed the study, performed data curation and statistical analysis, and wrote the original draft of the manuscript. Z.G. (Zhiyuan Guo) contributed to surgical procedures, patient enrollment, and clinical data collection. J.T. (Jian Tang) assisted in laboratory assays and inflammatory marker detection. L.Z. (Linsen Zhou) participated in data interpretation and visualization. Q.S. (Qiuyue She) supported follow-up data collection and literature review. H.J. (Haohai Jiang) helped with surgical coordination and technical guidance. J.Z. (Jianmin Zhang) supervised the clinical implementation and provided critical revisions. L.T. (Liming Tang), as the corresponding author, supervised the entire project, obtained funding, and finalized the manuscript. All authors reviewed and approved the final version of the manuscript.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eJiang Y, Wang P, Wang H, et al. 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PMID: 40200962; PMCID: PMC11974606.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZhang S, Lu X, Chen J, et al. Promotion of angiogenesis and suppression of inflammatory response in skin wound healing using exosome-loaded collagen sponge. Front Immunol. 2024;15:1511526. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3389/fimmu.2024.1511526\\u003c/span\\u003e\\u003cspan address=\\\"10.3389/fimmu.2024.1511526\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. PMID: 39669582; PMCID: PMC11634875.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eXu W, Xu T, Yu L, et al. Nanofibrous dressings incorporating a synergistic antibacterial-anti-inflammatory effect for infected wound healing. Mater Today Bio. 2025;34:102155. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/j.mtbio.2025.102155\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.mtbio.2025.102155\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. PMID: 40893349; PMCID: PMC12395525.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bsur\",\"sideBox\":\"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bsur/default.aspx\",\"title\":\"BMC Surgery\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Gastric cancer, Perioperative inflammatory response, Anastomotic technique, Interleukin-6, C-reactive protein\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8645414/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8645414/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eObjective\\u003c/h2\\u003e \\u003cp\\u003eAlthough laparoscopic surgery for gastric cancer has matured, the selection of the optimal anastomotic method (circular stapler [CS] vs. linear stapler [LS]) remains lacking in objective evidence based on patient biological responses. This study prospectively evaluated the dynamic changes in perioperative systemic inflammatory responses and their implications for guiding the choice of surgical approach (totally laparoscopic distal gastrectomy [TLDG] vs. totally laparoscopic total gastrectomy [LTG]) and anastomotic technique.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eThis prospective observational cohort study enrolled 180 patients undergoing radical laparoscopic gastrectomy. Patients were divided into four groups: TLDG-CS (n\\u0026thinsp;=\\u0026thinsp;50), TLDG-LS (n\\u0026thinsp;=\\u0026thinsp;50), LTG-CS (n\\u0026thinsp;=\\u0026thinsp;40), and LTG-LS (n\\u0026thinsp;=\\u0026thinsp;40). The CS groups underwent anastomosis using a novel laparoscopic purse-string suture clamp (Lap-PSC) combined with a multi-functional sealing cap (MSC). Serum levels of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and high-sensitivity C-reactive protein (hs-CRP) were measured preoperatively (T0), and at 24 hours (T1), 72 hours (T2), and 7 days (T3) postoperatively. The primary endpoint was the dynamic trajectory of inflammatory markers; secondary endpoints included surgical outcomes, postoperative recovery, and complications.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eBaseline characteristics were balanced among groups. Operative time was significantly shorter in the TLDG-CS group compared to TLDG-LS (148.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;21.5 vs. 172.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;28.4 minutes, p\\u0026thinsp;=\\u0026thinsp;0.003). Inflammatory markers peaked at T1 and declined thereafter. At T2, IL-6 and hs-CRP levels were significantly lower in CS groups compared to LS groups for both TLDG and LTG (e.g., TLDG-CS vs. TLDG-LS IL-6: 82.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;28.1 vs. 115.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;35.7 pg/mL, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Multivariate linear regression confirmed that LS was an independent predictor of higher IL-6 (β\\u0026thinsp;=\\u0026thinsp;28.4, 95%CI: 15.7\\u0026ndash;41.1, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) and hs-CRP (β\\u0026thinsp;=\\u0026thinsp;12.3, 95%CI: 6.8\\u0026ndash;17.8, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) at T2. The overall anastomosis-related complication rate was significantly lower in the CS group (3.3% vs. 8.9%, p\\u0026thinsp;=\\u0026thinsp;0.048).\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eDynamic perioperative inflammatory responses are sensitive indicators of surgical trauma and prognosis. In totally laparoscopic gastric cancer surgery, circular stapling assisted by Lap-PSC and MSC significantly attenuates systemic inflammatory responses and is associated with a lower risk of anastomotic complications compared to linear stapling. Monitoring inflammatory dynamics may provide an objective biological basis for personalized surgical-anastomotic strategy selection, advancing gastric cancer surgery toward greater precision.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Optimization of Anastomotic Strategy in Totally Laparoscopic Gastric Cancer Surgery Based on Dynamic Inflammatory Response Trajectories: A Prospective Cohort Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-02-15 14:26:09\",\"doi\":\"10.21203/rs.3.rs-8645414/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-02-23T08:08:13+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-19T12:40:38+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-16T13:36:45+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"261666977038918373225335435225555940924\",\"date\":\"2026-02-11T13:59:36+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-10T17:28:07+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"274554951687235349930877315910475177268\",\"date\":\"2026-02-10T17:19:48+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-10T09:45:02+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"257798756704422342583743005990089166474\",\"date\":\"2026-02-10T06:09:56+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"231891430231441213852513799302007462468\",\"date\":\"2026-02-10T05:12:32+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-02-10T03:58:53+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-02-05T10:40:32+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-02-05T10:37:39+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Surgery\",\"date\":\"2026-01-20T05:49:54+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bsur\",\"sideBox\":\"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bsur/default.aspx\",\"title\":\"BMC Surgery\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"22e3563a-0959-4815-8f7a-4c6a0f68a0b0\",\"owner\":[],\"postedDate\":\"February 15th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-13T16:01:03+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-8645414\",\"link\":\"https://doi.org/10.1186/s12893-026-03711-8\",\"journal\":{\"identity\":\"bmc-surgery\",\"isVorOnly\":false,\"title\":\"BMC Surgery\"},\"publishedOn\":\"2026-04-06 15:58:04\",\"publishedOnDateReadable\":\"April 6th, 2026\"},\"versionCreatedAt\":\"2026-02-15 14:26:09\",\"video\":\"\",\"vorDoi\":\"10.1186/s12893-026-03711-8\",\"vorDoiUrl\":\"https://doi.org/10.1186/s12893-026-03711-8\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8645414\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8645414\",\"identity\":\"rs-8645414\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}