Short-Term Outcomes and Pathological Features of Laparoscopic Versus Open Radical Total Gastrectomy for pT4a Gastric Cancer

AIM: The oncologic safety of laparoscopic radical total gastrectomy for pT4a gastric cancer remains debated, and the potential modifying role of Lauren histotype is unclear. This study aimed to develop an individualized prediction model for prolonged postoperative hospital stay to support risk-stratified rehabilitation. Secondary analyses compared perioperative outcomes between laparoscopic and open surgery, while exploratory subgroup analyses assessed potential effects of Lauren subtype.METHODS: This single-center retrospective cohort study included consecutive patients with pT4a gastric adenocarcinoma undergoing radical total gastrectomy at General Hospital of Ningxia Medical University from January 2021 to December 2025. Among 302 patients, 153 underwent laparoscopic surgery and 149 underwent open surgery. One-to-one propensity score matching (PSM) generated a balanced cohort of 248 patients. Univariable and multivariable logistic regression identified independent predictors of prolonged postoperative hospital stay. Model performance was evaluated using receiver operating characteristic (ROC) curves, calibration analysis, decision curve analysis (DCA), and SHapley Additive exPlanations (SHAP). A nomogram was constructed for individualized risk estimation. Perioperative and oncological outcomes were compared, and interaction analyses were performed to explore potential effect modification by Lauren subtype.RESULTS: After PSM, baseline characteristics were well balanced (all standardized mean differences <0.1). Multivariable analysis identified laparoscopic surgery (odds ratio [OR] = 0.47, 95% confidence interval [CI] 0.27–0.82, p = 0.008), specific N-stage categories and histological differentiation categories were associated with a lower risk of prolonged hospitalization, whereas increased intraoperative blood loss was associated with prolonged hospitalization. The prediction model achieved an area under the curve (AUC) of 0.73 (95% CI 0.67–0.79), with good calibration and clinical utility across threshold probabilities of 0.1–0.7. SHAP analysis indicated Node (N) stage and surgical approach as the two most influential predictors. Compared with open surgery, laparoscopic gastrectomy resulted in shorter incision length, reduced blood loss, earlier drain removal, and shorter postoperative and overall hospital stays (all p < 0.05), despite longer operative time. No significant differences were observed in lymph node retrieval, positive lymph node counts, or N stage distribution. Exploratory analyses demonstrated consistent favorable trends of laparoscopic surgery across Lauren subtypes, but no significant interaction was detected between surgical approach and Lauren classification (all pinteraction > 0.05).CONCLUSIONS: Laparoscopic surgery, histological differentiation, N stage, and intraoperative blood loss independently predict prolonged postoperative hospitalization after radical total gastrectomy for pT4a gastric cancer. The proposed model may provide preliminary risk stratification for patients undergoing radical total gastrectomy for pT4a gastric cancer, although further validation is required. Laparoscopic D2 radical total gastrectomy offers comparable lymph node retrieval and pathological outcomes with improved short-term recovery outcomes. The potential influence of Lauren subtype requires validation in larger multicenter cohorts.