Currently, the guideline provides no clear recommendation regarding preferred surgical approach —minimally invasive versus open resection—for patients with gastric cancer. This may lead to variability in clinical practice and uncertainty in treatment selection. Given the potential advantages of minimally invasive surgery, such as reduced postoperative morbidity and faster recovery, it is important to determine whether these benefits are achieved without compromising oncological outcomes. Clarifying this could lead to more standardized care and improved short- and long-term health outcomes for patients.  

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Description of studies

A total of 4 studies were included in the analysis of the literature. Important study characteristics and results are summarized in table 2. The assessment of the risk of bias is summarized in the risk of bias tables (under the tab ‘Evidence tabellen’).

Systematic review of Jiang, 2022

• A systematic literature search was performed from inception until December 2021. Studies were considered eligible if they included adult patients (aged 18 years and older) diagnosed with advanced gastric cancer (AGC) and compared laparoscopic surgery for gastrectomy with open surgery for gastrectomy. The reported outcomes included short-term metrics such as postoperative complications, the number of retrieved lymph nodes, surgical time, blood loss, length of hospital stay, and short-term mortality (defined as in-hospital mortality and mortality within 30 days after the operation). Long-term outcomes assessed comprised survival rates at 1, 3, and 5 years, with a specific focus on overall survival (OS) and disease-free survival (DFS) rates. The study design was restricted to randomized controlled trials (RCTs).

Invidual study STOMACH trial

• A non-inferiority, multicenter, international randomized trial took place from January 2015 to June 2018 across 13 hospitals in six European countries: the Netherlands, Sweden, Spain, Italy, Germany, and the United Kingdom. Eligible patients had resectable adenocarcinoma of the stomach and underwent neoadjuvant chemotherapy, with total gastrectomy indicated based on tumor location. Participants had to be over 18 years old and classified as American Society of Anesthesiologists (ASA) 3 or lower. Those with early gastric cancer suitable for local treatment, distal gastric cancer eligible for distal gastrectomy, gastro-esophageal junction tumors, prior stomach surgery, or a history of other malignancies were excluded from the study.

Individual study of Etoh, 2023

• This study conducted an open-label, multi-institutional, prospective, randomized phase 2/3, focusing on patients with gastric adenocarcinoma in 37 participants hospitals in Japan between November 26, 2009, and July 29, 2016. Participants were eligible if they between 20 and 80 years, a BMI less than 30.

Individual study of Xing, 2024

• This study conducted a multicenter, non-inferiority, open label randomized clinical trial focusing on patients with gastric adenocarcinoma from five tertiary hospitals in China. Participants were eligible if they were 18 years and older and with no prior chemotherapy, immunotherapy or radiotherapy.

Table 2. Characteristics of included studies

_{*For further details, see risk of bias table in the appendix}

Results

Survival (critical)

Overall survival was reported in 3 studies (Jiang,2022; STOMACH; Xing, 2024) but in different measurement outcomes.

1.1 1-year survival

1-year survival was reported in 8 studies. The overall HR was 1.05 (95% CI, 0.91 to 1.22) when comparing patients who underwent Laparoscopy (n=1651) to those who underwent Open surgery (n=1626). The difference was considered not clinically relevant (figure 1).

_{Figure 1. 1-year survival in patients who underwent Laparoscopy compared Open surgery}

1 year-survival was reported as a rate in one study (STOMACH trial). The 1-year survival rate was 85.5% in the Laparoscopy group (n=47) compared to 90.4% in the Open surgery group (n=49). HR was not reported so the clinically relevant difference could not be assessed, and these data were not added to the pooled data.

1.2 3-years survival

3-years survival was reported in 8 studies. The overall HR was 0.95 (95% CI, 0.82 to 1.10) when comparing patients who underwent Laparoscopy (n=1651) to those who underwent Open surgery (n=1626). The difference was considered not clinically relevant (figure 2).

_{Figure 2. 3-years survival in patients who underwent Laparoscopy compared Open surgery}

1.3 5-years survival

5-years survival was reported in 5 studies. The overall HR was 1.03 (95% CI, 0.86 to 1.24) when comparing patients who underwent Laparoscopy (=1021) to those who underwent Open surgery (n=1025). The difference was considered not clinically relevant (figure 3).

_{Figure 3. 5-years survival in patients who underwent Laparoscopy compared Open surgery}

Complications (critical)

Complications were reported in 14 studies. The risk difference was -0.02 (95% CI, -0.05 to 0.01) when comparing patients who underwent Laparoscopy (n=2333) to those who underwent Open surgery (n=2324). This difference was considered not clinically relevant (figure 4).

_{Figure 4. Complications in patients who underwent Laparoscopy compared Open surgery}

Quality of life (critical)
Quality of life (QoL) was reported in two studies, the LOGICA trial and the STOMACH trial, utilizing the EORTC-QLQ-C30 questionnaire. Additionally, the STOMACH trial used the EQ-5D. Both assessment tools use a Likert scale ranging from 0 to 100, where higher scores indicate a better quality of life.

In the STOMACH trial, one year after surgery, the overall health score using the EQ-5D was 68 (range: 50 to 83.8) for the Laparoscopy group (n=47) and 85 (range: 60 to 90) for the open surgery group (n=49), resulting in a difference of 17 points. The median overall health score from the EORTC-QLQ-C30 one-year post-surgery was 58.3 (range: 35.4 to 66.7) for the Laparoscopy group and 83.3 (range: 66.7 to 83.3) for the open surgery group, resulting in a difference of 25 points. These differences were considered clinically relevant in favor of open surgery.

In the LOGICA trial, only mean differences were reported (see Table 3), and these differences were considered not clinically relevant.

Table 3. QLQ-C30 global health-related quality of life score in patients who underwent Laparoscopy compared Open surgery. Source: LOGICA-trial

Length of hospital stay (important)

Length of hospital stay in days was reported in 11 studies. The mean difference was between Laparoscopy (n=1997) and Open surgery (n=1980) was -1.25 (95% CI, -2.09 to -0.41) days. This difference was considered clinically relevant in favor of Laparoscopy (figure 5).

_{Figure 5. Length of hospital stay in patients who underwent Laparoscopy compared Open surgery}

R0 resection (important)

R0 resection was reported in 5 studies. A total of 796 out of 815 resections were performed in the Laparoscopy group compared to 777 resections out of 798 in the Open surgery group. The risk difference was -0.01 (95% CI, -0.02 to 0.03). This difference was considered not clinically relevant (figure 6).

_{Figure 6. R0 resection in patients who underwent Laparoscopy compared Open surgery}

Lymph node retrieval (important)

Lymph node retrieval was reported as the number of resected lymph nodes in 13 studies. The mean difference between Laparoscopy (n=2099) and Open surgery (n=2088) was -1.05 (95% CI, -1.80 to -0.31). This difference was considered not clinically relevant (figure 7).

_{Figure 7. Lymph node retrieval in patients who underwent Laparoscopy compared Open surgery}

Pain (important)

Pain was assessed in the Stomach trial using the EORTC QLQ-C30 pain symptom scale. In the LOGICA trial, pain was evaluated using both the EORTC QLQ-C30 and the QLQ-STO22 pain symptom scales. Scores on these scales range from 0 to 100, with higher scores indicating more severe symptoms. The Stomach trial did not provide individual data but indicated that there were no differences in pain scores between the Laparoscopy group (n = 40) and the open surgery group (n = 37). In the LOGICA trial, only mean differences were reported (table 4, 5). This difference was considered not clinically relevant.

Table 4. EORTC QLQ-C30 pain score in patients who underwent Laparoscopy compared Open surgery. Source: STOMACH- trial

Table 5. QLQ-STO22 pain score in patients who underwent Laparoscopy compared Open surgery. Source: LOGICA-trial

Time to recovery (important)

No studies reported on time to recovery.

A systematic review of the literature was performed to answer the following question(s):

What is the role of minimally invasive surgery compared to open surgery in patients with gastric carcinoma?

Table 1. PICO

Relevant outcome measures

The guideline development group considered survival, complications and quality of life and as critical outcome measures for decision making and pain, time to recovery, length of hospital stay, R0 resection and lymph node retrieval as important outcome measures for decision making.

A priori, the guideline panel did not define the outcome measures listed above but used the definitions used in the studies.

The guideline panel defined minimal clinically (patient) important differences for the following outcomes:

• Survival: >5% or >3% and HR<0.70 and >1.43.
• Complications: Absolute difference ≥1% for lethal complications, or ≥5% for severe complications.
• Quality of life: A difference of 10 points on the quality of life instrument EORTC QLQ-C30 or a difference of a similar magnitude on other quality of life instruments.
• Pain: Change of 10 on 100mm (1 on 10) Visual Analogue Scale (VAS) (Myles, 2017) .
• Time to recovery: > 1 week.
• Length of hospital stay: > 1 day.
• R0 resection: Absolute difference >5% or absolute difference >3% with a Hazard Ratio (HR) <0.7.
• Lymph node retrieval: Number of resected lymph nodes >10% difference.

Search and select (Methods)

A systematic literature search was performed by a medical information specialist using the following bibliographic databases: Embase.com and Ovid/Medline. Both databases were searched from 2011 to 2025 for systematic reviews and RCTs. Systematic searches were completed using a combination of controlled vocabulary/subject headings (e.g., Emtree-terms, MeSH) wherever they were available and natural language keywords. The overall search strategy was derived from 2 primary search concepts: (1) Stomach carcinoma; (2) minimal invasive surgery. Duplicates were removed using EndNote software. After deduplication a total of 1225 records were imported for title/abstract screening. Initially, 13 studies were selected based on title and abstract screening. After reading the full text, 9 studies were excluded (see the exclusion table under the tab ‘Evidence tabellen’), and 4 studies were included.