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Stage IV gastric cancer (N=464)

Laparoscopy group (N=36)

Open group (N=81) Gastric resection group

(N=117)

347 patients excluded

108 Peritoneal biopsy 147 Bypass surgery

66 Ineligible for inclusion criteria

26 Open conversion from laparoscopy

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Laparoscopy (N=36) Open (N=36) p value

Age (year) 55.6 ± 16.0 54.9 ± 13.4 0.830

Sex 0.813

Male 21 (58.3%) 19 (52.8%)

Female 15 (41.7%) 17 (47.2%)

BMI (kg/m²)

21.8 ± 2.5 21.4 ± 3.4 0.566

ASA score 0.888

1 20 (55.6%) 20 (55.6%)

2 14 (38.9%) 13 (36.1%)

3 2 (5.6%) 3 (8.3%)

Gastrectomy type 0.344

Total 22 (61.1%) 17 (47.2%)

Distal 14 (38.9%) 19 (52.8%)

Combined resection (patient) 0.809

No 23 (63.9%) 21 (58.3%)

Yes 13 (36.1%) 15 (41.7%)

LN Dissection 0.322

D2 26 (72.2%) 21 (58.3%)

D2+ 10 (27.8%) 15 (41.7%)

Residual primary tumor 1.000

Negative 33 (91.7%) 34 (94.4%)

Positive 3 (8.3%) 2 (5.6%)

Operation time (min) 257.4 ± 80.2 224.3 ± 92.1 0.108 Estimated Blood Loss (mL) 134.4 ± 144.6 285.7 ± 540.4 0.113

Intraperitoneal CTx 1.000

No 29 (80.6%) 29 (80.6%)

Yes 7 (19.4%) 7 (19.4%)

Postop Cx (patient) 0.670

No 34 (94.4%) 32 (88.9%)

Yes 2 (5.6%) 4 (11.1%)

pT stage 0.872

T2 1 (2.8%) 2 (5.6%)

T3 5 (13.9%) 6 (16.7%)

T4a 25 (69.4%) 22 (61.1%)

T4b 5 (13.9%) 6 (16.7%)

pN stage 0.887

N1 1 (2.8%) 2 (5.6%)

N2 4 (11.1%) 4 (11.1%)

N3a 8 (22.2%) 6 (16.7%)

N3b 23 (63.9%) 24 (66.7%)

Retrieved LN (n) 71.1 ± 32.9 67.1 ± 24.5 0.561

Differentiation 0.193

Poorly Diff 11 (30.6%) 16 (44.4%)

Moderately Diff 6 (16.7%) 9 (25.0%)

Poorly Cohesive

Carcinoma 14 (38.9%) 6 (16.7%)

Others (Mixed, Mucinous) 5 (13.9%) 5 (13.9%)

Borrmann type 0.056

I 3 (8.3%) 0 (0.0%)

II 0 (0.0%) 5 (13.9%)

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III 21 (58.3%) 20 (55.6%)

IV 12 (33.3%) 10 (27.8%)

Unclassifiable 0 (0.0%) 1 (2.8%)

Stage IV type 0.349

Peritoneal carcinomatosis 25 (69.4%) 19 (52.8%) Distant LN metastasis 9 (25.0%) 14 (38.9%) Distant organ metastasis 2 (5.6%) 3 (8.3%)

Washing Cytology 0.214

Malignant 6 (16.7%) 5 (13.9%)

Negative 13 (36.1%) 7 (19.4%)

Not done 17 (47.2%) 24 (66.7%)

Palliative CTx 1.000

No 4 (11.1%) 4 (11.1%)

Yes 32 (88.9%) 32 (88.9%)

Time to CTx (days) 54.8 ± 113.7 38.4 ± 26.3 0.448 CTx cycle, median [range] 12.0 [1-73] 14.4 [1-82] 0.468 Abbreviations: BMI Body Mass Index, ASA American Society of Anesthesiologist, LN Lymph node, CTx Chemotherapy, Cx Complication, pT pathologic T stage, pN pathologic N stage, Diff

Differentiation,

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p = 0.929

0.25 0.50 0.75 1.00

0 30 60 90 120 150

Time

Survival Probability

Laparoscopy Open Open conversion

36 11 3 2 1 0

81 29 17 9 3 1

26 9 5 2 0 0

Open conversion Open Laparoscopy Numbers at risk

p = 0.882

0.25 0.50 0.75 1.00

0 30 60 90 120

Time

Survival Probability

Laparoscopy Open

36 11 3 2 1

36 14 7 3 1

Open Laparoscopy Numbers at risk

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0.2 0.4 0.6 0.8 1.0

0 30 60 90 120 150

Time

Survival Probability

18 9 5 4 1 1

All

Numbers at risk

REGATTA’s 2-year Survival Rate

Chemotherapy alone (N=86): 31.7% (Median 16.6 m) Surgery + Chemotherapy (N=89): 25.1% (Median 14.3 m)

MR = 1.874 2-year Survival Rate : 55.6% (Median 26.8 m)

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Complication Laparoscopy (N=36)^a Open (N=81)^a p value

Total (cases, %) 2 (5.6%) 19 (23.4%)^b 0.069

Wound problem 0 (0%) 3 (15.8%)

Pulmonary problem 1 (50%) 5 (26.3%)

Anastomosis site leakage 0 (0%) 2 (10.5%)

Bleeding 0 (0%) 3 (15.8%)

Intraabdominal abscess 0 (0%) 3 (15.8%)

Ileus 1 (50%) 2 (10.5%)

Pancreatic fistula 0 (0%) 0 (0%)

Lymphatic leakage 0 (0%) 1 (5.3%)

Clavien-Dindo ≥ Grade 3 (case) 1 / 36 (2.8%) 10 / 81 (12.3%)

Mortality 0 (0%) 0 (0%)

a Before propensity score matching

b 19 cases in 17 patients

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Variables Univariate analysis Multivariate analysis

HR 95% CI p value HR 95% CI p value

Age 1.02 1.00 – 1.04 0.074

Sex 1.06 0.63 – 1.77 0.826

ASA score 1.30 0.87 – 1.95 0.200

Open vs. Laparoscopy 1.05 0.57 – 1.91 0.883 Combined resection 1.39 0.83 – 2.32 0.211 LN dissection 1.13 0.54 – 2.40 0.740 Differentiation

Poorly diff. 0.90 0.44 – 1.86 0.782 Moderately diff. 2.06 0.92 – 4.64 0.081

PCC 1.26 0.59 – 2.69 0.543

Tumor type

Borrmann type III 1.35 0.32 – 5.68 0.678 Borrmann type IV 1.43 0.33 – 6.10 0.632 Residual primary tumor 2.04 0.73 – 5.66 0.172 Peritoneal carcinomatosis 0.81 0.45 – 1.47 0.493 Distant organ metastasis 0.55 0.16 – 1.90 0.344 Malignant cytology 0.46 0.19 – 1.09 0.077 Intraperitoneal CTx. 0.91 0.50 – 1.66 0.759

Palliative CTx. 0.32 0.15 – 0.65 0.002 0.38 0.15 – 0.95 0.040 Chemotherapy cycle 0.86 0.82 – 0.90 <0.001 0.86 0.82 – 0.90 <0.001 Postoperative Cx. 4.00 1.54 – 10.41 0.004 3.96 1.26 – 12.36 0.017

19 No.

of cases

Approach Surgery 2-year OSR

3-year OSR

5-year OSR

Median (months) Cx

Our study

36 Lap G, M 41.7% 34.7% 23.4% 17.9 5.6%

81 Open G, M 47.2% 33.3% 25% 22.8 23.4%

Chang

2011[16] 25 Open G, M - 10.1% - 13.2 -

Yang

2013[17] 30 Open G, M - 23.3% - - -

Fujitani

2016[15] 87 Open G only 25.1% - - 14.3 16%

Seo

2018[18] 124 Open G, M - 37.1% - - 25%

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