Adopting Minimally Invasive Approaches for Managing Gastric Adenocarcinoma in a Low-Incidence Country Center: Feasibility and Limitations

Adopting Minimally Invasive Approaches for Managing Gastric Adenocarcinoma in a Low-Incidence Country Center: Feasibility and Limitations | 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 Adopting Minimally Invasive Approaches for Managing Gastric Adenocarcinoma in a Low-Incidence Country Center: Feasibility and Limitations Hamza Ouzzaouit, Hamza Sekkat, Youssef Achour, Bakali Youness, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8584830/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Backgroud Gastric adenocarcinoma (GA) remains a major cause of cancer-related mortality worldwide and is frequently diagnosed at an advanced stage in low-incidence countries. Although laparoscopic gastrectomy has become standard for early gastric cancer, its feasibility in locally advanced disease and in low-volume settings remains debated. This study aimed to evaluate the feasibility and short-term outcomes of laparoscopic gastrectomy in a low-incidence country with a high prevalence of locally advanced tumors. Methods We conducted a retrospective single-center study including all consecutive patients who underwent curative gastrectomy for histologically confirmed GA between January 2019 and December 2023. Patients were divided into laparoscopic (LG) and open gastrectomy (OG) groups. Intraoperative variables, postoperative complications (Clavien–Dindo classification), oncological outcomes, and 90-day mortality were compared. Results A total of 51 patients underwent curative resection, including 15 (29.4%) in the LG group. Most patients presented with locally advanced disease (T3–T4: 84.3%). Operative time was longer in the LG group but not significantly different from OG. Postoperative morbidity, reoperation rate, and 90-day mortality were comparable between the two groups. The LG group had a shorter postoperative hospital stay. Oncological outcomes, including R0 resection rate and number of lymph nodes retrieved, were similar between LG and OG. Conclusions In a low-incidence country with a high proportion of locally advanced gastric adenocarcinoma, laparoscopic gastrectomy appears to be a feasible and safe alternative to open surgery in selected patients, providing comparable short-term surgical and oncological outcomes with the potential benefit of faster postoperative recovery. Gastric adenocarcinoma Laparoscopic gastrectomy Open gastrectomy Minimally invasive surgery Low-incidence country Locally advanced gastric cancer Surgical outcomes Retrospective study I Introduction Gastric cancer ranks as the fifth most common malignancy worldwide and remains the fifth leading cause of cancer-related mortality [ 1 ]. Although its global incidence has declined over recent decades, gastric cancer was responsible for approximately 660,000 deaths in 2022, according to data from GLOBOCAN 2022 [ 30 ]. Gastric adenocarcinoma (GA) accounts for the vast majority of these cases. In our national context, GA represents the second most common digestive cancer [ 2 ], with an incidence estimated at 4.2 per 100,000 population among women and 6.9 per 100,000 population among men [ 30 ]. Despite these figures, our country is still classified as a low-incidence region compared with several Asian and Western countries [ 3 ]. Nevertheless, GA continues to pose a significant public health challenge due to its often late presentation and poor prognosis. Current international guidelines recommend a multimodal treatment strategy for gastric cancer; however, surgical resection remains the cornerstone of curative treatment [ 4 ]. Over the past three decades, minimally invasive surgical techniques have profoundly transformed the management of digestive malignancies. Laparoscopic gastrectomy has progressively evolved with technological advancements and is now widely adopted, particularly for early-stage gastric cancer [ 5 ]. Several studies have demonstrated the advantages of laparoscopy over open surgery, including reduced intraoperative blood loss, decreased postoperative pain, faster recovery of bowel function, improved quality of life, and shorter hospital stays [ 5 ]. Despite these benefits, the laparoscopic approach remains technically demanding and its indications, particularly in locally advanced gastric cancer, continue to be debated [ 6 ]. In low-incidence countries, surgeons are frequently confronted with advanced or metastatic disease at diagnosis [ 7 ]. A Moroccan study published in 2013 highlighted the national epidemiological landscape, characterized by heterogeneous dietary habits and a high prevalence of Helicobacter pylori infection, affecting more than 70% of patients with peptic ulcer disease [ 7 ]. This high prevalence constitutes a well-established risk factor for GA. In addition, significant delays in patient consultation—often exceeding six months—have been reported, resulting in more than half of patients being diagnosed at a metastatic stage [ 7 ]. These epidemiological and clinical characteristics explain the challenges associated with the adoption of minimally invasive approaches in our setting. Consequently, the primary objective of this study was to evaluate the feasibility and reproducibility of laparoscopic gastrectomy for gastric adenocarcinoma in a low-incidence country characterized by a high proportion of locally advanced tumors. We aimed to compare intraoperative and short-term postoperative outcomes of curative gastric resections performed using laparoscopic and conventional open approaches II Methods Study Design and Data Collection We conducted a retrospective single-center study comparing early surgical outcomes between open gastrectomy (OG) and laparoscopic gastrectomy (LG) in patients who underwent curative resection for gastric adenocarcinoma (GA). Data were extracted from a prospectively maintained institutional database including all consecutive patients operated on for GA between January 2019 and December 2023. The database contained demographic, preoperative, intraoperative, and postoperative data, with follow-up extending up to 90 days after surgery. Data were collected using a standardized data collection form and subsequently analyzed using statistical software. This study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [ 32 ]. Patient Selection All consecutive adult patients (≥ 18 years) who underwent curative partial or total gastrectomy for histologically confirmed gastric adenocarcinoma were eligible for inclusion. Tumors were located between 2 cm below the esophagogastric junction (Z-line) and the pylorus. Patients undergoing surgery with palliative intent were excluded from the analysis. During the study period, a total of 129 patients were admitted for gastric adenocarcinoma, of whom 51 underwent curative resection and were included in the final analysis. All included patients were followed for a minimum of 90 days postoperatively, with systematic recording of postoperative complications and mortality. Follow-up data were validated until March 1, 2023. Surgical Procedures Curative gastrectomy was defined as en bloc resection of the tumor with macroscopically negative resection margins and a minimum of D1.5 lymphadenectomy. The D1.5 lymphadenectomy consisted of removal of lymph node stations 1, 3, 4sb, 4d, 5, 6, 7, 8a, 9, and 11p, without complete extension to D2 dissection, which additionally includes stations 10, 11d, and 12a [ 31 ]. Among the 51 included patients, detailed lymphadenectomy data were available for 49 patients. The choice of surgical approach (open or laparoscopic) and type of reconstruction was left to the discretion of the operating surgeon. No predefined selection criteria were applied. All procedures were performed by three senior surgeons with extensive experience in open esophagogastric surgery. Two of these surgeons have routinely performed laparoscopic gastrectomy for gastric cancer since 2015, after having initiated laparoscopic surgery in 2004 within an academic surgical department. Outcome Measures The primary endpoint was the overall postoperative complication rate within 90 days after surgery. Secondary endpoints included intraoperative parameters (operative time), severity of postoperative complications according to the Clavien–Dindo classification, rate of R0 resection, number of lymph nodes retrieved, length of postoperative hospital stay, and 90-day mortality. Postoperative morbidity and mortality were assessed using the Clavien–Dindo classification system. Complications were graded from I to V, with Grades I–II considered minor complications, Grades III–IV considered severe or life-threatening complications, and Grade V corresponding to postoperative death. Statistical Analysis Qualitative variables were expressed as frequencies and percentages (n, %). Quantitative variables were presented as medians or means with corresponding measures of dispersion, as appropriate. Comparisons between groups were performed using the chi-square test (χ²) for categorical variables. A P value < 0.05 was considered statistically significant. Statistical analyses were performed using Jamovi software. III Results Descriptive Analysis The demographic, clinical, and pathological characteristics of patients who underwent laparoscopic gastrectomy (LG) and open gastrectomy (OG) are summarized in Table 1 . A total of 51 patients were included in the study. The mean age was 55.5 ± 12.6 years, with a male-to-female ratio of 0.88, indicating a slight female predominance. Most patients were classified as American Society of Anesthesiologists (ASA) physical status I or II (98%), and only one patient was classified as ASA III. Performance status was 0–1 in 49 patients (96.1%). Body mass index (BMI) was < 25 kg/m² in 43 patients (84.3%). Nineteen patients (37.3%) were malnourished, defined by a serum albumin level < 30 g/L, and 22 patients (43.1%) presented with anemia (hemoglobin < 10 g/dL). Tumors were most frequently located in the fundus (47.1%) or antropyloric region (45.1%), while total gastric involvement was observed in four patients (7.8%). Moderately differentiated adenocarcinoma was the most common histological subtype (37.3%). Most patients presented with locally advanced disease: 43 patients (84.3%) had T3–T4 tumors, while eight patients (15.7%) had T1–T2 tumors. Lymph node involvement was present in 31 patients (60.8%). Nine patients (17.6%) required emergency surgery due to bleeding or gastric outlet obstruction. Neoadjuvant chemotherapy was administered to 34 patients (66.6%). The laparoscopic approach was performed in 15 patients (29.4%), with a conversion rate of 13.3%. Total gastrectomy was performed in 28 patients (54.9%), and D1.5 lymphadenectomy was achieved in 43 patients (84.3%). Surgical margins were negative (R0) in 45 patients (88.2%), with a median of 23.5 lymph nodes retrieved. Only one patient (1.9%) developed a digestive fistula. Five patients (9.8%) required reoperation, and four patients (7.8%) died within 90 days postoperatively. The mean length of hospital stay was 7.9 days. The median follow-up was 18.6 months. Follow-up data were unavailable for 18 patients; 20 patients were alive without disease recurrence at the time of analysis. Due to the limited follow-up duration, disease-free survival and overall survival could not be reliably assessed. Comparison Between Open and Laparoscopic Gastrectomy Baseline characteristics were comparable between the LG and OG groups with respect to age (p = 0.260), sex (p = 0.056), BMI (p = 0.300), hemoglobin level (p = 0.110), albumin level (p = 0.565), and tumor marker positivity (CEA: p = 0.411; CA 19 − 9: p = 0.072). Tumor location did not differ significantly between groups (p = 0.975). In the LG group, seven patients (46.6%) had antropyloric tumors and seven (46.6%) had fundic tumors, whereas one patient (6.7%) had total gastric involvement. In the OG group, fundic tumors were observed in 17 patients (47.2%), antropyloric tumors in 16 patients (44.4%), and total gastric tumors in three patients (8.3%). Regarding tumor stage, locally advanced disease (T3–T4) was more frequent in the OG group (94.4%) compared with the LG group (60%), and this difference was statistically significant (p = 0.005). Lymph node involvement was similar between groups (LG: 66.6% vs. OG: 58.3%; p = 0.662). There were no significant differences between the two groups in terms of type of gastrectomy performed (p = 0.784) or extent of lymphadenectomy (p = 0.590). Perioperative Outcomes Fifteen patients underwent laparoscopic surgery, with a conversion rate of 13.3%. Operative time was shorter in the OG group (median 212.5 minutes) compared with the LG group (256 minutes), although this difference was not statistically significant (p = 0.240). Wound infections occurred more frequently in the OG group (8.3%) than in the LG group (6.7%), while a single digestive fistula was observed in the OG group only. These differences were not statistically significant. Reoperations were required in five patients: three in the OG group (8.3%) and two in the LG group (13.3%) (p = 0.463). Two postoperative deaths occurred in each group, with no significant difference in mortality (p = 0.336). Postoperative hospital stay was shorter in the LG group (6.7 ± 2.1 days) than in the OG group (8.5 ± 3.1 days), although this difference did not reach statistical significance (p = 0.206). The mean number of lymph nodes retrieved was comparable between groups (LG: 24.4 ± 7.0 vs. OG: 22.7 ± 8.0; p = 0.597). Positive distal resection margins were observed in three patients in each group (p = 0.234). Table 1 Descriptive table of results for our study population (51 patients) Variable Result Age, mean (SD) in years 55.6(12.6) Male gender 24(47.05%) Performance status 0–1 49(96.07%) > 1 2 (3.93%) ASA score 1–2 50 (98%) > 2 1 (2%) Body mass index (Kg/m2) 25 7(13,7%) Missing 1 Albumine 25 g/l 30g/l 32(62.7%) Hemoglobine 10g/dl 29(56.8%) ACE (Positive) 11(21.56%) CA 19.9 (Positive) 7(13.7%) Tumor location Pylor 23 (45.09%) fundus 24 (47.05%) Toto-gastric 4 (7.8%) Neoadjuvant chemoradiotherapy 34(66.6%) Type of surgery Total gastrectomy 28 (54.9%) Partial gastrectomy 23 (45.09%) Associated resection No 38 (74.5%) Yes 13 (25.4%) pT stage 0–2 8 (15.6%) 3–4 43 (84.3%) pN stage N0 20 (39.2%) N1 30 (58.8%) N2 1 (3.2%) M stage M0 48 (94.1%) M1 3(5.88%) Positive distal margin 6 (11.76%) Operating time (minutes) 229.3 Number of nodes removed 23.55 Clavien Dindo 1–2 43(84.3%) 3–4 4(7.84%) 5 4(7.84%) Anastomotic leakage*/** 1 (1.9%) Revision surgery* 5 (9.8%) Mortality* 4 (7.8%) SD : Standard deviation ASA : American score of anesthesiologists *90-days morbidity **48 anastomosis performed. Table 2 Comparative table between the two populations LG and OG with p value Variable LG (N = 15) OG (N = 36) P Age (SD) years 56.8 55.05 0.260 Gender 0.056 Men 4 (26.6%) 20 (55.5%) Women 11 (73.3%) 16 (44.5%) Performance status 0.627 0–1 15 (100%) 34 (94.4%) > 1 0(0%) 2 (12%) ASA score 0.551 1–2 15 (100%) 35 (97.2%) > 2 0 (0%) 1 (2.8%) Body mass index (Kg/m2) 0.300 25 3 (20%) 4 (11.2%) Albumine(g/l) 0.565 30 30 9(60%) 23(63.8) Hemoglobine (g/l) 0.110 10 11(73.3) 18(50%) ACE(Positive) 0 4(11.1%) 0.411 CA19.9(Positive) 0 7(19.44%) 0.072 T stage 0.005 0–2 6 (40%) 2 (5.5%) 3–4 9 (60%) 34(94.4%) N stage 0.662 N0 5(33.3%) 15 (41.6%) N1 10 (66.6%) 20 (55.5%) N2 0 1 (2.7%) M stage 0.343 M0 15(100%) 33 (91.6%) M1 0(0%) 3 (8.4%) Neo-adjuvant Chemotherapy 9(60%) 25(69.4%) 0.37 Type of surgery 0.784 Total gastrectomy 8(53.3%) 20(55.5%) Partial gastrectomy 7(46.6%) 16(44.5%) Radical lymph node resection 0.59 D1.5 14(93.3%) 28(77.77%) D2 1(6.7%) 6(16.66%) Operating time (minutes) 256 212.5 0.240 Wall infection 1(6.66%) 3(8.33%) 0.664 Digestive fistula 0 1(2.77%) 0.706 Surgical revision 2(13.3%) 3(8.33%) 0.463 Length of hospital stay (Days) 6.7 8.5 0.206 Claviene-Dindo 0.168 1–2 10(66.6%) 33(91.6% ) 3–4 3(20%) 1(2.7%) 5 2(13.3%) 2(5.55%) Number of nodes removed 22.4 22.7 0.597 Positive distal margin 3(20%) 3(8.33%) 0.234 Mortality 2(13.3%) 2(5.55%) Discussion The demographic profile of patients included in this study reflects several specific characteristics of gastric adenocarcinoma (GA) in our national context. GA is uncommon before the age of 45 in both sexes [ 9 ]; however, the mean age of our cohort was 55.5 years, which is considerably younger than that reported in Western countries. For instance, in France, the average age at diagnosis is 70.1 years for men and 75.2 years for women. This discrepancy may be explained by differences in dietary habits, the high prevalence of Helicobacter pylori infection from an early age, and delayed management of precancerous gastric conditions [ 9 ]. A notable finding of our study is the high proportion of patients presenting with locally advanced disease, as 84.3% of tumors were classified as T3–T4. This observation is consistent with previously published national data and is likely attributable to delayed patient consultation and the absence of a structured national screening program [ 10 ]. These epidemiological features pose significant challenges for surgical management, particularly in low-incidence countries where early detection is less common. Since its introduction by Kitano in 1991 [ 4 ], minimally invasive gastric surgery has primarily been applied to early-stage gastric cancer and has since been validated by numerous randomized trials and meta-analyses [ 5 – 11 ]. Over time, technological progress and improved surgical expertise have expanded the indications of laparoscopic gastrectomy (LG), with demonstrated benefits including reduced intraoperative blood loss, faster recovery of bowel function, earlier resumption of oral intake, improved cosmetic outcomes, and shorter hospital stays [ 12 – 14 ]. Nevertheless, LG remains a technically demanding procedure with a steep learning curve, which has limited its widespread adoption, particularly in low-volume centers [ 12 , 13 ]. Several factors contribute to this complexity, including restricted operative fields, limited tactile feedback, reduced instrument flexibility, and the technical difficulty of performing intracorporeal digestive anastomoses [ 15 ]. Most studies suggest that surgical proficiency in LG is achieved after approximately 50–60 cases [ 16 ], although some authors have reported shorter learning curves, particularly among surgeons with prior extensive experience in advanced laparoscopic procedures [ 17 ]. In our series, operative time was longer in the LG group, although this difference did not reach statistical significance. This finding is consistent with previous meta-analyses reporting longer operative times for LG compared with open gastrectomy (OG) [ 18 , 19 ]. The increased duration of laparoscopic procedures has been attributed to the technical difficulty of lymph node dissection, total omentectomy, and limitations inherent to laparoscopic visualization and instrumentation [ 19 ]. Curative resection remains the cornerstone of GA treatment, with complete tumor removal and negative resection margins (R0) being key indicators of surgical quality [ 4 ]. Our study demonstrated no significant difference in resection margin status between LG and OG, in agreement with existing literature. Large multicenter studies and meta-analyses have shown comparable oncological radicality between laparoscopic and open approaches, even in locally advanced disease [ 20 – 23 ]. Importantly, similar long-term survival outcomes have been reported despite minor differences in proximal or distal margin lengths [ 21 ]. Adequate lymph node dissection is another critical determinant of oncological quality, as it ensures accurate staging and reduces the risk of locoregional recurrence [ 1 – 4 ]. Current recommendations advocate the retrieval of at least 15 lymph nodes, while recent evidence suggests that harvesting more than 23 nodes may further improve survival outcomes [ 13 – 15 , 23 ]. In our study, the number of lymph nodes retrieved was comparable between LG and OG groups, supporting the oncological adequacy of laparoscopic lymphadenectomy in experienced hands. These findings are consistent with large European randomized trials and pooled analyses demonstrating no significant differences in lymph node yield between the two approaches [ 24 ]. Postoperative morbidity and mortality are essential indicators of surgical safety. In our cohort, postoperative fistulas occurred exclusively in the OG group, while rates of reoperation and mortality were comparable between LG and OG. Although these findings suggest a potential advantage of the minimally invasive approach, no definitive consensus exists regarding the superiority of one technique over the other in terms of postoperative complications [ 25 ]. Several meta-analyses have reported lower rates of wound infection, postoperative bleeding, and anastomotic leakage following LG, with similar or lower mortality rates compared with OG [ 13 , 26 – 28 ]. These results are in line with our observations. Despite the low incidence of GA in Morocco, our findings demonstrate that laparoscopic gastrectomy can be safely performed in selected patients, even in the context of predominantly locally advanced disease. However, achieving the case volume required to overcome the learning curve remains challenging in low-incidence settings [ 29 ]. Cost considerations also represent a barrier to the widespread implementation of LG, as the use of disposable laparoscopic instruments increases procedural costs. Nevertheless, reduced hospital stays and faster postoperative recovery may partially offset these expenses [ 28 ]. Limitations This study has several limitations. First, its retrospective and single-center design may limit the generalizability of the findings. Second, the relatively small sample size reduces statistical power and precludes adjusted analyses for potential confounding factors such as comorbidities, tumor stage, or surgeon experience. Third, follow-up duration was limited and incomplete, preventing reliable assessment of disease-free and overall survival outcomes. Consequently, the observed differences between laparoscopic and open gastrectomy should be interpreted with caution and cannot be considered evidence of a causal relationship. Future multicenter prospective studies with larger cohorts and longer follow-up periods are required to confirm the long-term oncological outcomes of laparoscopic gastrectomy in low-incidence countries. Conclusion In conclusion, this retrospective single-center study suggests that laparoscopic gastrectomy is a feasible and safe alternative to open gastrectomy for the treatment of gastric adenocarcinoma in a low-incidence country setting. Despite the high proportion of locally advanced tumors, laparoscopic gastrectomy demonstrated comparable short-term postoperative morbidity and mortality to open surgery, while offering the potential benefit of shorter postoperative hospital stay. Although limited by a relatively small sample size, retrospective design, and short follow-up duration, these findings support the use of minimally invasive approaches in carefully selected patients when performed by experienced surgeons. Further prospective multicenter studies with larger cohorts and longer follow-up are warranted to confirm long-term oncological outcomes and to better define the role of laparoscopic gastrectomy in low-incidence regions. Declarations Data Availability Statement The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Consent for publication: Not applicable. Competing interests: The authors have no conflicts of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Human Ethics and Consent to Participate This retrospective study was approved by the Ethics Committee of Mohammed V University in Rabat. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Given the retrospective nature of the study and the use of anonymized patient data, the requirement for informed consent to participate was waived by the Ethics Committee. Clinical trial registration Not applicable. Acknowledgements The authors would like to thank the surgical and nursing staff involved in the management of the patients included in this study. 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Evolution in Laparoscopic Gastrectomy from a Randomized Controlled Trial Through National Clinical Practice. Ann Surg. 2024 Mar 1;279(3):394-401. doi: 10.1097/SLA.0000000000006162. PMID: 37991188; PMCID: PMC10829898. Davey MG, Temperley HC, O'Sullivan NJ, Marcelino V, Ryan OK, Ryan ÉJ, Donlon NE, Johnston SM, Robb WB. Minimally Invasive and Open Gastrectomy for Gastric Cancer: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials. Ann Surg Oncol. 2023 Sep;30(9):5544-5557. doi: 10.1245/s10434-023-13654-6. PMID: 37261563; PMCID: PMC10409677. Caruso S, Giudicissi R, Mariatti M, Cantafio S, Paroli GM, Scatizzi M. Laparoscopic vs. Open Gastrectomy for Locally Advanced Gastric Cancer: A Propensity Score-Matched Retrospective Case-Control Study. Curr Oncol. 2022 Mar 9;29(3):1840-1865. doi: 10.3390/curroncol29030151. PMID: 35323351; PMCID: PMC8947505. Pang, HY., Chen, XF., Chen, LH. et al. Comparisons of perioperative and long-term outcomes of laparoscopic versus open gastrectomy for advanced gastric cancer after neoadjuvant therapy: an updated pooled analysis of eighteen studies. Eur J Med Res 28, 224 (2023). https://doi.org/10.1186/s40001-023-01197-1 Van der Wielen N, Brenkman H, Seesing M, Daams F, Ruurda J, van der Veen A, van der Peet DL, Straatman J, van Hillegersberg R; STOMACH and LOGICA study group. Minimally invasive versus open gastrectomy for gastric cancer. A pooled analysis of two European randomized controlled trials. J Surg Oncol. 2024 Apr;129(5):911-921. doi: 10.1002/jso.27578.. PMID: 38173355. Van der Veen A, Brenkman HJF, Seesing MFJ, Haverkamp L, Luyer MDP, Nieuwenhuijzen GAP, Stoot JHMB, Tegels JJW, Wijnhoven BPL, Lagarde SM, de Steur WO, Hartgrink HH, Kouwenhoven EA, Wassenaar EB, Draaisma WA, Gisbertz SS, van der Peet DL, May AM, Ruurda JP, van Hillegersberg R; LOGICA Study Group. Laparoscopic Versus Open Gastrectomy for Gastric Cancer (LOGICA): A Multicenter Randomized Clinical Trial. J Clin Oncol. 2021 Mar 20;39(9):978-989. doi: 10.1200/JCO.20.01540 .PMID: 34581617. X. Rod, D. Fuks, R. Macovei, H. Levard, J.-M. Ferraz, C. Denet, C. Tubbax, B. Gayet, T. Perniceni Comparison between open and laparoscopic gastrectomy for gastric cancer: A monocentric retrospective study from a western country-Journal of Visceral Surgery, Volume 155, Issue 2, April 2018, Pages 91-97 https://doi.org/10.1016/j.jchirv.2017.05.007 Tsekrekos A, Vossen LE, Lundell L, Jeremiasen M, Johnsson E, Hedberg J, Edholm D, Klevebro F, Nilsson M, Rouvelas I. Improved survival after laparoscopic compared to open gastrectomy for advanced gastric cancer: a Swedish population-based cohort study. Gastric Cancer. 2023 May;26(3):467-477. doi: 10.1007/s10120-023-01371-8. PMID: 36808262; PMCID: PMC10115725. Miura S, Kodera Y, Fujiwara M, Ito S, Mochizuki Y, Yamamura Y, Hibi K, Ito K, Akiyama S, Nakao A. Laparoscopy-assisted distal gastrectomy with systemic lymph node dissection: a critical reappraisal from the viewpoint of lymph node retrieval. J Am Coll Surg. 2004; 198:933–8. https://doi.org/10.1016/j.jamcollsurg.2004.01.021. Tu RH, Lin M, Lin JX, Wu SZ, Xie JW, Wang JB, Lu J, Chen QY, Cao LL, Zheng CH, Huang CM, Li P. Laparoscopic radical gastrectomy for gastric cancer: Long-term outcome in a teaching center. Asian J Surg. 2024 Jan;47(1):459-465. doi: 10.1016/j.asjsur.2023.10.002. PMID: 37879983. GLOBOCAN. (2022). Global cancer observatory: Cancer today . International Agency for Research on Cancer (IARC). https://gco.iarc.fr/today Ichikura, T., Chochi, K., Sugasawa, H. et al. Modified radical lymphadenectomy (D1.5) for T2–3 gastric cancer. Langenbecks Arch Surg 390 , 397–402 (2005). https://doi.org/10.1007/s00423-005-0570-7 von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007;147:573-577. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 27 Feb, 2026 Reviewers agreed at journal 27 Feb, 2026 Reviewers invited by journal 17 Feb, 2026 Editor assigned by journal 16 Feb, 2026 Editor invited by journal 27 Jan, 2026 Submission checks completed at journal 26 Jan, 2026 First submitted to journal 26 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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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-8584830","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":592659705,"identity":"fc5eeab5-544f-498d-b893-fd90238a9e04","order_by":0,"name":"Hamza Ouzzaouit","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYBACA3SuHAMD/wOStBgYMzDwkGQLg0FiAyEt5uynkz/8YLBJnN9/+OFjnoI/6RuunT32gaHGjkG3/QBWLZY9uRsMexjSEhsbjhkb8xgY5G64nZc8g+FYMoPZmQTsDjuQuyGBh+FwYjNjg5k0REsC0D9sBxjMDuDQcv7thoN/gFramNm/gbSkG4C1/ANqOf8Au5YbuRubQbb0sPGAbUkwuJ1jzMDYBtRyA4ctN95uZpYxSDOewcNTbDjHwNhw5u20ZIbEvmQesxs4bDmfu/njmwob2fn9xzc+ePNHTp7vdvJhhg/f7OTMzmO3BaoRXSCBYISOglEwCkbBKMAHAAkSXMLup6JjAAAAAElFTkSuQmCC","orcid":"","institution":"Mohammed V University","correspondingAuthor":true,"prefix":"","firstName":"Hamza","middleName":"","lastName":"Ouzzaouit","suffix":""},{"id":592659706,"identity":"56ac6547-e952-422a-a402-e6914dc9d9d4","order_by":1,"name":"Hamza Sekkat","email":"","orcid":"","institution":"Mohammed V University","correspondingAuthor":false,"prefix":"","firstName":"Hamza","middleName":"","lastName":"Sekkat","suffix":""},{"id":592659707,"identity":"5e7a9ea1-abe0-4477-a43a-a44c8e081f9d","order_by":2,"name":"Youssef Achour","email":"","orcid":"","institution":"Mohammed V University","correspondingAuthor":false,"prefix":"","firstName":"Youssef","middleName":"","lastName":"Achour","suffix":""},{"id":592659708,"identity":"ba42c01a-cced-43fc-81e2-ab05d1fe03d8","order_by":3,"name":"Bakali Youness","email":"","orcid":"","institution":"Mohammed V University","correspondingAuthor":false,"prefix":"","firstName":"Bakali","middleName":"","lastName":"Youness","suffix":""},{"id":592659709,"identity":"af6327ea-9934-424b-8baf-6646f074eae1","order_by":4,"name":"Sabbah Farid","email":"","orcid":"","institution":"Mohammed V University","correspondingAuthor":false,"prefix":"","firstName":"Sabbah","middleName":"","lastName":"Farid","suffix":""},{"id":592659710,"identity":"d78ebf34-4ba2-4139-9878-4c07b86b900c","order_by":5,"name":"Mhamdi Alaoui Mouna","email":"","orcid":"","institution":"Mohammed V University","correspondingAuthor":false,"prefix":"","firstName":"Mhamdi","middleName":"Alaoui","lastName":"Mouna","suffix":""},{"id":592659711,"identity":"394977e7-cf6c-437d-8572-7522bf3af240","order_by":6,"name":"Hrora Abdelmalek","email":"","orcid":"","institution":"Mohammed V University","correspondingAuthor":false,"prefix":"","firstName":"Hrora","middleName":"","lastName":"Abdelmalek","suffix":""},{"id":592659712,"identity":"c8a299f9-9222-4130-ad33-e808246a08b6","order_by":7,"name":"Raiss Mohamed","email":"","orcid":"","institution":"Mohammed V University","correspondingAuthor":false,"prefix":"","firstName":"Raiss","middleName":"","lastName":"Mohamed","suffix":""}],"badges":[],"createdAt":"2026-01-12 19:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8584830/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8584830/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103017348,"identity":"b6cbd4ce-3016-459a-9529-827073ec2ab3","added_by":"auto","created_at":"2026-02-19 16:56:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1064364,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8584830/v1/3d04061d-eb54-490d-955e-18c95ab03b03.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Adopting Minimally Invasive Approaches for Managing Gastric Adenocarcinoma in a Low-Incidence Country Center: Feasibility and Limitations","fulltext":[{"header":"I Introduction","content":"\u003cp\u003eGastric cancer ranks as the fifth most common malignancy worldwide and remains the fifth leading cause of cancer-related mortality [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although its global incidence has declined over recent decades, gastric cancer was responsible for approximately 660,000 deaths in 2022, according to data from GLOBOCAN 2022 [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Gastric adenocarcinoma (GA) accounts for the vast majority of these cases.\u003c/p\u003e \u003cp\u003eIn our national context, GA represents the second most common digestive cancer [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], with an incidence estimated at 4.2 per 100,000 population among women and 6.9 per 100,000 population among men [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Despite these figures, our country is still classified as a low-incidence region compared with several Asian and Western countries [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Nevertheless, GA continues to pose a significant public health challenge due to its often late presentation and poor prognosis.\u003c/p\u003e \u003cp\u003eCurrent international guidelines recommend a multimodal treatment strategy for gastric cancer; however, surgical resection remains the cornerstone of curative treatment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Over the past three decades, minimally invasive surgical techniques have profoundly transformed the management of digestive malignancies. Laparoscopic gastrectomy has progressively evolved with technological advancements and is now widely adopted, particularly for early-stage gastric cancer [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Several studies have demonstrated the advantages of laparoscopy over open surgery, including reduced intraoperative blood loss, decreased postoperative pain, faster recovery of bowel function, improved quality of life, and shorter hospital stays [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite these benefits, the laparoscopic approach remains technically demanding and its indications, particularly in locally advanced gastric cancer, continue to be debated [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In low-incidence countries, surgeons are frequently confronted with advanced or metastatic disease at diagnosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A Moroccan study published in 2013 highlighted the national epidemiological landscape, characterized by heterogeneous dietary habits and a high prevalence of \u003cem\u003eHelicobacter pylori\u003c/em\u003e infection, affecting more than 70% of patients with peptic ulcer disease [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This high prevalence constitutes a well-established risk factor for GA. In addition, significant delays in patient consultation\u0026mdash;often exceeding six months\u0026mdash;have been reported, resulting in more than half of patients being diagnosed at a metastatic stage [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese epidemiological and clinical characteristics explain the challenges associated with the adoption of minimally invasive approaches in our setting. Consequently, the primary objective of this study was to evaluate the feasibility and reproducibility of laparoscopic gastrectomy for gastric adenocarcinoma in a low-incidence country characterized by a high proportion of locally advanced tumors. We aimed to compare intraoperative and short-term postoperative outcomes of curative gastric resections performed using laparoscopic and conventional open approaches\u003c/p\u003e"},{"header":"II Methods","content":"\u003cp\u003eStudy Design and Data Collection\u003c/p\u003e \u003cp\u003eWe conducted a retrospective single-center study comparing early surgical outcomes between open gastrectomy (OG) and laparoscopic gastrectomy (LG) in patients who underwent curative resection for gastric adenocarcinoma (GA). Data were extracted from a prospectively maintained institutional database including all consecutive patients operated on for GA between January 2019 and December 2023.\u003c/p\u003e \u003cp\u003eThe database contained demographic, preoperative, intraoperative, and postoperative data, with follow-up extending up to 90 days after surgery. Data were collected using a standardized data collection form and subsequently analyzed using statistical software.\u003c/p\u003e \u003cp\u003eThis study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePatient Selection\u003c/p\u003e \u003cp\u003eAll consecutive adult patients (\u0026ge;\u0026thinsp;18 years) who underwent curative partial or total gastrectomy for histologically confirmed gastric adenocarcinoma were eligible for inclusion. Tumors were located between 2 cm below the esophagogastric junction (Z-line) and the pylorus.\u003c/p\u003e \u003cp\u003ePatients undergoing surgery with palliative intent were excluded from the analysis. During the study period, a total of 129 patients were admitted for gastric adenocarcinoma, of whom 51 underwent curative resection and were included in the final analysis.\u003c/p\u003e \u003cp\u003eAll included patients were followed for a minimum of 90 days postoperatively, with systematic recording of postoperative complications and mortality. Follow-up data were validated until March 1, 2023.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSurgical Procedures\u003c/p\u003e \u003cp\u003eCurative gastrectomy was defined as en bloc resection of the tumor with macroscopically negative resection margins and a minimum of D1.5 lymphadenectomy. The D1.5 lymphadenectomy consisted of removal of lymph node stations 1, 3, 4sb, 4d, 5, 6, 7, 8a, 9, and 11p, without complete extension to D2 dissection, which additionally includes stations 10, 11d, and 12a [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong the 51 included patients, detailed lymphadenectomy data were available for 49 patients.\u003c/p\u003e \u003cp\u003eThe choice of surgical approach (open or laparoscopic) and type of reconstruction was left to the discretion of the operating surgeon. No predefined selection criteria were applied.\u003c/p\u003e \u003cp\u003eAll procedures were performed by three senior surgeons with extensive experience in open esophagogastric surgery. Two of these surgeons have routinely performed laparoscopic gastrectomy for gastric cancer since 2015, after having initiated laparoscopic surgery in 2004 within an academic surgical department.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOutcome Measures\u003c/p\u003e \u003cp\u003eThe primary endpoint was the overall postoperative complication rate within 90 days after surgery.\u003c/p\u003e \u003cp\u003eSecondary endpoints included intraoperative parameters (operative time), severity of postoperative complications according to the Clavien\u0026ndash;Dindo classification, rate of R0 resection, number of lymph nodes retrieved, length of postoperative hospital stay, and 90-day mortality.\u003c/p\u003e \u003cp\u003ePostoperative morbidity and mortality were assessed using the Clavien\u0026ndash;Dindo classification system. Complications were graded from I to V, with Grades I\u0026ndash;II considered minor complications, Grades III\u0026ndash;IV considered severe or life-threatening complications, and Grade V corresponding to postoperative death.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eQualitative variables were expressed as frequencies and percentages (n, %). Quantitative variables were presented as medians or means with corresponding measures of dispersion, as appropriate.\u003c/p\u003e \u003cp\u003eComparisons between groups were performed using the chi-square test (χ\u0026sup2;) for categorical variables. A \u003cem\u003eP\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Statistical analyses were performed using Jamovi software.\u003c/p\u003e \u003c/div\u003e"},{"header":"III Results","content":"\u003cp\u003eDescriptive Analysis\u003c/p\u003e \u003cp\u003eThe demographic, clinical, and pathological characteristics of patients who underwent laparoscopic gastrectomy (LG) and open gastrectomy (OG) are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eA total of 51 patients were included in the study. The mean age was 55.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6 years, with a male-to-female ratio of 0.88, indicating a slight female predominance. Most patients were classified as American Society of Anesthesiologists (ASA) physical status I or II (98%), and only one patient was classified as ASA III. Performance status was 0\u0026ndash;1 in 49 patients (96.1%).\u003c/p\u003e \u003cp\u003eBody mass index (BMI) was \u0026lt;\u0026thinsp;25 kg/m\u0026sup2; in 43 patients (84.3%). Nineteen patients (37.3%) were malnourished, defined by a serum albumin level\u0026thinsp;\u0026lt;\u0026thinsp;30 g/L, and 22 patients (43.1%) presented with anemia (hemoglobin\u0026thinsp;\u0026lt;\u0026thinsp;10 g/dL). Tumors were most frequently located in the fundus (47.1%) or antropyloric region (45.1%), while total gastric involvement was observed in four patients (7.8%). Moderately differentiated adenocarcinoma was the most common histological subtype (37.3%).\u003c/p\u003e \u003cp\u003eMost patients presented with locally advanced disease: 43 patients (84.3%) had T3\u0026ndash;T4 tumors, while eight patients (15.7%) had T1\u0026ndash;T2 tumors. Lymph node involvement was present in 31 patients (60.8%). Nine patients (17.6%) required emergency surgery due to bleeding or gastric outlet obstruction. Neoadjuvant chemotherapy was administered to 34 patients (66.6%).\u003c/p\u003e \u003cp\u003eThe laparoscopic approach was performed in 15 patients (29.4%), with a conversion rate of 13.3%. Total gastrectomy was performed in 28 patients (54.9%), and D1.5 lymphadenectomy was achieved in 43 patients (84.3%). Surgical margins were negative (R0) in 45 patients (88.2%), with a median of 23.5 lymph nodes retrieved.\u003c/p\u003e \u003cp\u003eOnly one patient (1.9%) developed a digestive fistula. Five patients (9.8%) required reoperation, and four patients (7.8%) died within 90 days postoperatively. The mean length of hospital stay was 7.9 days.\u003c/p\u003e \u003cp\u003eThe \u003cb\u003emedian follow-up\u003c/b\u003e was 18.6 months. Follow-up data were unavailable for 18 patients; 20 patients were alive without disease recurrence at the time of analysis. Due to the limited follow-up duration, disease-free survival and overall survival could not be reliably assessed.\u003c/p\u003e \u003cp\u003eComparison Between Open and Laparoscopic Gastrectomy\u003c/p\u003e \u003cp\u003eBaseline characteristics were comparable between the LG and OG groups with respect to age (p\u0026thinsp;=\u0026thinsp;0.260), sex (p\u0026thinsp;=\u0026thinsp;0.056), BMI (p\u0026thinsp;=\u0026thinsp;0.300), hemoglobin level (p\u0026thinsp;=\u0026thinsp;0.110), albumin level (p\u0026thinsp;=\u0026thinsp;0.565), and tumor marker positivity (CEA: p\u0026thinsp;=\u0026thinsp;0.411; CA 19\u0026thinsp;\u0026minus;\u0026thinsp;9: p\u0026thinsp;=\u0026thinsp;0.072).\u003c/p\u003e \u003cp\u003eTumor location did not differ significantly between groups (p\u0026thinsp;=\u0026thinsp;0.975). In the LG group, seven patients (46.6%) had antropyloric tumors and seven (46.6%) had fundic tumors, whereas one patient (6.7%) had total gastric involvement. In the OG group, fundic tumors were observed in 17 patients (47.2%), antropyloric tumors in 16 patients (44.4%), and total gastric tumors in three patients (8.3%).\u003c/p\u003e \u003cp\u003eRegarding tumor stage, locally advanced disease (T3\u0026ndash;T4) was more frequent in the OG group (94.4%) compared with the LG group (60%), and this difference was statistically significant (p\u0026thinsp;=\u0026thinsp;0.005). Lymph node involvement was similar between groups (LG: 66.6% vs. OG: 58.3%; p\u0026thinsp;=\u0026thinsp;0.662).\u003c/p\u003e \u003cp\u003eThere were no significant differences between the two groups in terms of type of gastrectomy performed (p\u0026thinsp;=\u0026thinsp;0.784) or extent of lymphadenectomy (p\u0026thinsp;=\u0026thinsp;0.590).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePerioperative Outcomes\u003c/p\u003e \u003cp\u003eFifteen patients underwent laparoscopic surgery, with a conversion rate of 13.3%. Operative time was shorter in the OG group (median 212.5 minutes) compared with the LG group (256 minutes), although this difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.240).\u003c/p\u003e \u003cp\u003eWound infections occurred more frequently in the OG group (8.3%) than in the LG group (6.7%), while a single digestive fistula was observed in the OG group only. These differences were not statistically significant.\u003c/p\u003e \u003cp\u003eReoperations were required in five patients: three in the OG group (8.3%) and two in the LG group (13.3%) (p\u0026thinsp;=\u0026thinsp;0.463). Two postoperative deaths occurred in each group, with no significant difference in mortality (p\u0026thinsp;=\u0026thinsp;0.336).\u003c/p\u003e \u003cp\u003ePostoperative hospital stay was shorter in the LG group (6.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1 days) than in the OG group (8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1 days), although this difference did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.206). The mean number of lymph nodes retrieved was comparable between groups (LG: 24.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0 vs. OG: 22.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0; p\u0026thinsp;=\u0026thinsp;0.597). Positive distal resection margins were observed in three patients in each group (p\u0026thinsp;=\u0026thinsp;0.234).\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\u003eDescriptive table of results for our study population (51 patients)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \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\u003eResult\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\u003eAge, mean (SD) in years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.6(12.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMale gender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24(47.05%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerformance status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49(96.07%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.93%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (98%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody mass index (Kg/m2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43(84.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(13,7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlbumine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;25 g/l\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(3.92%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;25 g/l\u0026lt;30g/l\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(33.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30g/l\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32(62.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHemoglobine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10g/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22(43.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10g/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29(56.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eACE (Positive)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(21.56%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCA 19.9 (Positive)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(13.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTumor location\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePylor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (45.09%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efundus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (47.05%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToto-gastric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeoadjuvant chemoradiotherapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34(66.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (54.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartial gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (45.09%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAssociated resection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (74.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (25.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003epT stage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (15.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (84.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003epN stage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\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\u003e20 (39.2%)\u003c/p\u003e \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\u003e30 (58.8%)\u003c/p\u003e \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\u003e1 (3.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eM stage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (94.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(5.88%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePositive distal margin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (11.76%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOperating time (minutes)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e229.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of nodes removed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClavien Dindo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43(84.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(7.84%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(7.84%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnastomotic leakage*/**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRevision surgery*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (9.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMortality*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eSD : Standard deviation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eASA : American score of anesthesiologists\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e*90-days morbidity\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e**48 anastomosis performed.\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\u003eComparative table between the two populations LG and OG with p value\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\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\u003eLG\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOG\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\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\u003eAge (SD) years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.260\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (26.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (55.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (73.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (44.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerformance status\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.627\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (94.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA score\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.551\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (97.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody mass index (Kg/m2)\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.300\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (88.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (11.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlbumine(g/l)\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.565\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;25\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(5.55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u0026thinsp;\u0026lt;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(30.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(63.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHemoglobine (g/l)\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.110\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eACE(Positive)\u003c/b\u003e\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\u003e4(11.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.411\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCA19.9(Positive)\u003c/b\u003e\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\u003e7(19.44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT stage\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34(94.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eN stage\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.662\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\u003e5(33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (41.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\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\u003e10 (66.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (55.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\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\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eM stage\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.343\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15(100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (91.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (8.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeo-adjuvant Chemotherapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25(69.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of surgery\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.784\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(53.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(55.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartial gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(46.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(44.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRadical lymph node resection\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(93.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28(77.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(16.66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOperating time (minutes)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e256\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e212.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.240\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWall infection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(6.66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(8.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.664\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDigestive fistula\u003c/b\u003e\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\u003e1(2.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.706\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgical revision\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(13.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(8.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.463\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of hospital stay (Days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClaviene-Dindo\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(66.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33(91.6% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(13.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(5.55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of nodes removed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.597\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePositive distal margin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(8.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.234\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMortality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(13.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(5.55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe demographic profile of patients included in this study reflects several specific characteristics of gastric adenocarcinoma (GA) in our national context. GA is uncommon before the age of 45 in both sexes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]; however, the mean age of our cohort was 55.5 years, which is considerably younger than that reported in Western countries. For instance, in France, the average age at diagnosis is 70.1 years for men and 75.2 years for women. This discrepancy may be explained by differences in dietary habits, the high prevalence of \u003cem\u003eHelicobacter pylori\u003c/em\u003e infection from an early age, and delayed management of precancerous gastric conditions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA notable finding of our study is the high proportion of patients presenting with locally advanced disease, as 84.3% of tumors were classified as T3\u0026ndash;T4. This observation is consistent with previously published national data and is likely attributable to delayed patient consultation and the absence of a structured national screening program [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These epidemiological features pose significant challenges for surgical management, particularly in low-incidence countries where early detection is less common.\u003c/p\u003e \u003cp\u003eSince its introduction by Kitano in 1991 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], minimally invasive gastric surgery has primarily been applied to early-stage gastric cancer and has since been validated by numerous randomized trials and meta-analyses [\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9 CR10\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Over time, technological progress and improved surgical expertise have expanded the indications of laparoscopic gastrectomy (LG), with demonstrated benefits including reduced intraoperative blood loss, faster recovery of bowel function, earlier resumption of oral intake, improved cosmetic outcomes, and shorter hospital stays [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNevertheless, LG remains a technically demanding procedure with a steep learning curve, which has limited its widespread adoption, particularly in low-volume centers [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Several factors contribute to this complexity, including restricted operative fields, limited tactile feedback, reduced instrument flexibility, and the technical difficulty of performing intracorporeal digestive anastomoses [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Most studies suggest that surgical proficiency in LG is achieved after approximately 50\u0026ndash;60 cases [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], although some authors have reported shorter learning curves, particularly among surgeons with prior extensive experience in advanced laparoscopic procedures [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our series, operative time was longer in the LG group, although this difference did not reach statistical significance. This finding is consistent with previous meta-analyses reporting longer operative times for LG compared with open gastrectomy (OG) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The increased duration of laparoscopic procedures has been attributed to the technical difficulty of lymph node dissection, total omentectomy, and limitations inherent to laparoscopic visualization and instrumentation [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurative resection remains the cornerstone of GA treatment, with complete tumor removal and negative resection margins (R0) being key indicators of surgical quality [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Our study demonstrated no significant difference in resection margin status between LG and OG, in agreement with existing literature. Large multicenter studies and meta-analyses have shown comparable oncological radicality between laparoscopic and open approaches, even in locally advanced disease [\u003cspan additionalcitationids=\"CR21 CR22\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Importantly, similar long-term survival outcomes have been reported despite minor differences in proximal or distal margin lengths [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdequate lymph node dissection is another critical determinant of oncological quality, as it ensures accurate staging and reduces the risk of locoregional recurrence [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Current recommendations advocate the retrieval of at least 15 lymph nodes, while recent evidence suggests that harvesting more than 23 nodes may further improve survival outcomes [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In our study, the number of lymph nodes retrieved was comparable between LG and OG groups, supporting the oncological adequacy of laparoscopic lymphadenectomy in experienced hands. These findings are consistent with large European randomized trials and pooled analyses demonstrating no significant differences in lymph node yield between the two approaches [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePostoperative morbidity and mortality are essential indicators of surgical safety. In our cohort, postoperative fistulas occurred exclusively in the OG group, while rates of reoperation and mortality were comparable between LG and OG. Although these findings suggest a potential advantage of the minimally invasive approach, no definitive consensus exists regarding the superiority of one technique over the other in terms of postoperative complications [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Several meta-analyses have reported lower rates of wound infection, postoperative bleeding, and anastomotic leakage following LG, with similar or lower mortality rates compared with OG [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. These results are in line with our observations.\u003c/p\u003e \u003cp\u003eDespite the low incidence of GA in Morocco, our findings demonstrate that laparoscopic gastrectomy can be safely performed in selected patients, even in the context of predominantly locally advanced disease. However, achieving the case volume required to overcome the learning curve remains challenging in low-incidence settings [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Cost considerations also represent a barrier to the widespread implementation of LG, as the use of disposable laparoscopic instruments increases procedural costs. Nevertheless, reduced hospital stays and faster postoperative recovery may partially offset these expenses [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis study has several limitations. First, its retrospective and single-center design may limit the generalizability of the findings. Second, the relatively small sample size reduces statistical power and precludes adjusted analyses for potential confounding factors such as comorbidities, tumor stage, or surgeon experience. Third, follow-up duration was limited and incomplete, preventing reliable assessment of disease-free and overall survival outcomes. Consequently, the observed differences between laparoscopic and open gastrectomy should be interpreted with caution and cannot be considered evidence of a causal relationship.\u003c/p\u003e \u003cp\u003eFuture multicenter prospective studies with larger cohorts and longer follow-up periods are required to confirm the long-term oncological outcomes of laparoscopic gastrectomy in low-incidence countries.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this retrospective single-center study suggests that laparoscopic gastrectomy is a feasible and safe alternative to open gastrectomy for the treatment of gastric adenocarcinoma in a low-incidence country setting. Despite the high proportion of locally advanced tumors, laparoscopic gastrectomy demonstrated comparable short-term postoperative morbidity and mortality to open surgery, while offering the potential benefit of shorter postoperative hospital stay.\u003c/p\u003e \u003cp\u003eAlthough limited by a relatively small sample size, retrospective design, and short follow-up duration, these findings support the use of minimally invasive approaches in carefully selected patients when performed by experienced surgeons. Further prospective multicenter studies with larger cohorts and longer follow-up are warranted to confirm long-term oncological outcomes and to better define the role of laparoscopic gastrectomy in low-incidence regions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study was approved by the Ethics Committee of Mohammed V University in Rabat.\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the ethical principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eGiven the retrospective nature of the study and the use of anonymized patient data, the requirement for informed consent to participate was waived by the Ethics Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the surgical and nursing staff involved in the management of the patients included in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eH.O. conceived and designed the study, collected the data, performed the statistical analysis, and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eH.S., Y.A., Y.B., M.M.A., F.S., A.H., and M.R. contributed to patient management, data interpretation, and critical revision of the manuscript.\u003cbr\u003eAll authors read and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZhang, C., Zhang, P., Yu, J. et al. 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Journal Africain du Cancer / African Journal of Cancer. 7. 10.1007/s12558-014-0322-4.\u003c/li\u003e\n\u003cli\u003eEpid\u0026eacute;miologie du cancer gastrique: exp\u0026eacute;rience d\u0026rsquo;un centre hospitalier marocain :Ihsane Mellouki, Nawal laazar, Bahija Benyachou, Nouredine Aqodad, Adil Ibrahimi,PanAfricanMedicalJournal.2014;17:42 doi:10.11604/pamj.2014.17.42.3342\u003c/li\u003e\n\u003cli\u003eOhtani, H.; Tamamori, Y.; Noguchi, K.; Azuma, T.; Fujimoto, S.; Oba, H.; Aoki, T.; Minami, M.; Hirakawa, K. A Meta-Analysis of Randomized Controlled Trials that Compared Laparoscopy-Assisted and Open Distal Gastrectomy for Early Gastric Cancer. J. Gastrointest. Surg. 2010, 14, 958\u0026ndash;964. \u003c/li\u003e\n\u003cli\u003eVamvakas EC. Perioperative blood transfusion and cancer recurrence: metaanalysis for explanation. Transfusion. 1995; 35:760\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eHakkenbrak NAG, Jansma EP, van der Wielen N, van der Peet DL, Straatman J. 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Gastroenterol. 2015, 21, 1606\u0026ndash;1613. \u003c/li\u003e\n\u003cli\u003eSeika P, Biebl M, Raakow J, Kr\u0026ouml;ll D, \u0026Ccedil;etinkaya-Hosg\u0026ouml;r C, Thuss-Patience P, Maurer MM, Dobrindt EM, Pratschke J, Denecke C. The Learning Curve for Hand-Assisted Laparoscopic Total Gastrectomy in Gastric Cancer Patients. J Clin Med. 2022 Nov 19;11(22):6841. doi: 10.3390/jcm11226841. PMID: 36431318; PMCID: PMC9698309.\u003c/li\u003e\n\u003cli\u003eKimura A., Ogata K., Kogure N., Yanoma T., Suzuki M., Toyomasu Y., Ohno T., Mochiki E., Kuwano H. Outcome of laparoscopic gastrectomy with D1 plus lymph node dissection in gastric cancer patients postoperatively diagnosed with locally advanced disease or lymph node metastasis. Surg. Endosc. 2016; 30:2090\u0026ndash;2096. doi: 10.1007/s00464-015-4462-9.\u003c/li\u003e\n\u003cli\u003eYan Yong, Ou Caiwen , Cao Shunwang , Hua Yinggang , Sha Yanhua (2023) Laparoscopic vs. open distal gastrectomy for locally advanced gastric cancer: A systematic review and meta-analysis of randomized controlled trials ,Frontiers in Surgery , VOLUME=10 DOI=10.3389/fsurg.2023.1127854\u003c/li\u003e\n\u003cli\u003eMarkar SR, Visser MR, van der Veen A, Luyer MDP, Nieuwenhuijzen G, Stoot JHMB, Tegels JJW, Wijnhoven BPL, Lagarde SM, de Steur WO, Hartgrink HH, Kouwenhoven EA, Wassenaar EB, Draaisma WA, Gisbertz SS, van Berge Henehouwen MI, van der Peet DL, Ruurda JP, van Hillegersberg R; LOGICA Study Group, Dutch Upper Gastrointestinal Cancer Audit Group. Evolution in Laparoscopic Gastrectomy from a Randomized Controlled Trial Through National Clinical Practice. Ann Surg. 2024 Mar 1;279(3):394-401. doi: 10.1097/SLA.0000000000006162. PMID: 37991188; PMCID: PMC10829898.\u003c/li\u003e\n\u003cli\u003eDavey MG, Temperley HC, O\u0026apos;Sullivan NJ, Marcelino V, Ryan OK, Ryan \u0026Eacute;J, Donlon NE, Johnston SM, Robb WB. Minimally Invasive and Open Gastrectomy for Gastric Cancer: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials. Ann Surg Oncol. 2023 Sep;30(9):5544-5557. doi: 10.1245/s10434-023-13654-6. PMID: 37261563; PMCID: PMC10409677.\u003c/li\u003e\n\u003cli\u003eCaruso S, Giudicissi R, Mariatti M, Cantafio S, Paroli GM, Scatizzi M. Laparoscopic vs. Open Gastrectomy for Locally Advanced Gastric Cancer: A Propensity Score-Matched Retrospective Case-Control Study. Curr Oncol. 2022 Mar 9;29(3):1840-1865. doi: 10.3390/curroncol29030151. PMID: 35323351; PMCID: PMC8947505.\u003c/li\u003e\n\u003cli\u003ePang, HY., Chen, XF., Chen, LH. \u003cem\u003eet al.\u003c/em\u003e Comparisons of perioperative and long-term outcomes of laparoscopic versus open gastrectomy for advanced gastric cancer after neoadjuvant therapy: an updated pooled analysis of eighteen studies. \u003cem\u003eEur J Med Res\u003c/em\u003e 28, 224 (2023). https://doi.org/10.1186/s40001-023-01197-1\u003c/li\u003e\n\u003cli\u003eVan der Wielen N, Brenkman H, Seesing M, Daams F, Ruurda J, van der Veen A, van der Peet DL, Straatman J, van Hillegersberg R; STOMACH and LOGICA study group. Minimally invasive versus open gastrectomy for gastric cancer. A pooled analysis of two European randomized controlled trials. J Surg Oncol. 2024 Apr;129(5):911-921. doi: 10.1002/jso.27578.. PMID: 38173355.\u003c/li\u003e\n\u003cli\u003eVan der Veen A, Brenkman HJF, Seesing MFJ, Haverkamp L, Luyer MDP, Nieuwenhuijzen GAP, Stoot JHMB, Tegels JJW, Wijnhoven BPL, Lagarde SM, de Steur WO, Hartgrink HH, Kouwenhoven EA, Wassenaar EB, Draaisma WA, Gisbertz SS, van der Peet DL, May AM, Ruurda JP, van Hillegersberg R; LOGICA Study Group. Laparoscopic Versus Open Gastrectomy for Gastric Cancer (LOGICA): A Multicenter Randomized Clinical Trial. J Clin Oncol. 2021 Mar 20;39(9):978-989. doi: 10.1200/JCO.20.01540 .PMID: 34581617.\u003c/li\u003e\n\u003cli\u003eX. Rod, D. Fuks, R. Macovei, H. Levard, J.-M. Ferraz, C. Denet, C. Tubbax, B. Gayet, T. Perniceni Comparison between open and laparoscopic gastrectomy for gastric cancer: A monocentric retrospective study from a western country-Journal of Visceral Surgery, Volume 155, Issue 2, April 2018, Pages 91-97 https://doi.org/10.1016/j.jchirv.2017.05.007\u003c/li\u003e\n\u003cli\u003eTsekrekos A, Vossen LE, Lundell L, Jeremiasen M, Johnsson E, Hedberg J, Edholm D, Klevebro F, Nilsson M, Rouvelas I. Improved survival after laparoscopic compared to open gastrectomy for advanced gastric cancer: a Swedish population-based cohort study. Gastric Cancer. 2023 May;26(3):467-477. doi: 10.1007/s10120-023-01371-8. PMID: 36808262; PMCID: PMC10115725.\u003c/li\u003e\n\u003cli\u003eMiura S, Kodera Y, Fujiwara M, Ito S, Mochizuki Y, Yamamura Y, Hibi K, Ito K, Akiyama S, Nakao A. Laparoscopy-assisted distal gastrectomy with systemic lymph node dissection: a critical reappraisal from the viewpoint of lymph node retrieval. J Am Coll Surg. 2004; 198:933\u0026ndash;8. https://doi.org/10.1016/j.jamcollsurg.2004.01.021.\u003c/li\u003e\n\u003cli\u003eTu RH, Lin M, Lin JX, Wu SZ, Xie JW, Wang JB, Lu J, Chen QY, Cao LL, Zheng CH, Huang CM, Li P. Laparoscopic radical gastrectomy for gastric cancer: Long-term outcome in a teaching center. Asian J Surg. 2024 Jan;47(1):459-465. doi: 10.1016/j.asjsur.2023.10.002. PMID: 37879983.\u003c/li\u003e\n\u003cli\u003eGLOBOCAN. (2022). \u003cstrong\u003eGlobal cancer observatory: Cancer today\u003c/strong\u003e. International Agency for Research on Cancer (IARC). https://gco.iarc.fr/today\u003c/li\u003e\n\u003cli\u003eIchikura, T., Chochi, K., Sugasawa, H. \u003cem\u003eet al.\u003c/em\u003e Modified radical lymphadenectomy (D1.5) for T2\u0026ndash;3 gastric cancer. \u003cem\u003eLangenbecks Arch Surg\u003c/em\u003e \u003cstrong\u003e390\u003c/strong\u003e, 397\u0026ndash;402 (2005). https://doi.org/10.1007/s00423-005-0570-7\u003c/li\u003e\n\u003cli\u003e\u003cem\u003evon Elm E, Altman DG, Egger M, et al. \u003c/em\u003e\u003cem\u003eThe Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. \u003c/em\u003e\u003cem\u003eAnn Intern Med. 2007;147:573-577.\u003c/em\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","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 adenocarcinoma, Laparoscopic gastrectomy, Open gastrectomy, Minimally invasive surgery, Low-incidence country, Locally advanced gastric cancer, Surgical outcomes, Retrospective study","lastPublishedDoi":"10.21203/rs.3.rs-8584830/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8584830/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackgroud\u003c/h2\u003e \u003cp\u003eGastric adenocarcinoma (GA) remains a major cause of cancer-related mortality worldwide and is frequently diagnosed at an advanced stage in low-incidence countries. Although laparoscopic gastrectomy has become standard for early gastric cancer, its feasibility in locally advanced disease and in low-volume settings remains debated. This study aimed to evaluate the feasibility and short-term outcomes of laparoscopic gastrectomy in a low-incidence country with a high prevalence of locally advanced tumors.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective single-center study including all consecutive patients who underwent curative gastrectomy for histologically confirmed GA between January 2019 and December 2023. Patients were divided into laparoscopic (LG) and open gastrectomy (OG) groups. Intraoperative variables, postoperative complications (Clavien\u0026ndash;Dindo classification), oncological outcomes, and 90-day mortality were compared.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 51 patients underwent curative resection, including 15 (29.4%) in the LG group. Most patients presented with locally advanced disease (T3\u0026ndash;T4: 84.3%). Operative time was longer in the LG group but not significantly different from OG. Postoperative morbidity, reoperation rate, and 90-day mortality were comparable between the two groups. The LG group had a shorter postoperative hospital stay. Oncological outcomes, including R0 resection rate and number of lymph nodes retrieved, were similar between LG and OG.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e In a low-incidence country with a high proportion of locally advanced gastric adenocarcinoma, laparoscopic gastrectomy appears to be a feasible and safe alternative to open surgery in selected patients, providing comparable short-term surgical and oncological outcomes with the potential benefit of faster postoperative recovery.\u003c/p\u003e","manuscriptTitle":"Adopting Minimally Invasive Approaches for Managing Gastric Adenocarcinoma in a Low-Incidence Country Center: Feasibility and Limitations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-19 16:56:19","doi":"10.21203/rs.3.rs-8584830/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-27T11:07:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231891430231441213852513799302007462468","date":"2026-02-27T10:42:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-17T09:27:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-16T14:20:42+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-27T05:48:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-26T15:58:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-01-26T15:54:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","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":"79b64de8-d13e-4c55-a91e-8d54e0594ddb","owner":[],"postedDate":"February 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-19T16:56:19+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-19 16:56:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8584830","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8584830","identity":"rs-8584830","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}