Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma

Objectives: The aim was to conduct a meta-analysis of the randomized evidence to determine the relative merits of laparoscopic assisted (LADG) and open (ODG) distal gastrectomy for proven gastric cancer. Data sources and review methods: A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified all randomized clinical trials (RCTs) that compared LADG and OGD and were published in the English language between January 1990 and the end of June 2007. The meta-analysis was prepared in accordance with the Quality of Reporting of Meta-analyses (QUOROM) statement. The eight outcome variables analysed were operating time, blood loss, retrieval of lymph nodes, oral intake, hospital stay, postoperative complications, tumour recurrence and mortality. Random effects meta-analyses were performed using odds ratios (OR) and weighted mean differences (WMD). Results: Four trials were considered suitable for meta-analysis. A total of 81 patients underwent LADG and 80 had ODG. For only one of the eight outcomes, the summary point estimates favoured LADG over ODG; there was a significant reduction of 104.26 mls in the intra-operative blood loss for LADG (WMD, -104.26, 95% confidence interval (c.i.) -189.01 to -19.51; P = 0.0159). There was however a 83.08 minutes longer duration of operating time for the LADG group compared with the ODG group (WMD 83.08, 95% c.i. 40.53 – 125.64; P = 0.0001) and significant reduction in lymph nodes harvesting of 4.34 lymph nodes in the LADG group (WMD -4.3, 95% c.i. -6.66 to -2.02; P = 0.0002). Other outcome variables such as time to commencement of oral intake (WMD -0.97, 95% c.i. -2.47 to 0.54 ; P = 0.2068); duration of hospital stay (WMD -3.32, 95% c.i. -7.69 to 1.05; P = 0.1365); rate of complications (OR 0.66, 95% c.i. 0.27 to 1.60; P = 0.3530); mortality rates (OR 0.94, 95% c.i. 0.21 – 4.19; P = 0.9363) and tumour recurrence (OR 1.08 (95% c.i. 0.42 – 2.79; P = 0.8806) were not found to be statistically significant for either group. However, for commencement of oral intake, duration of hospital stay and complication rate, the trend was in favour of LADG. Conclusion: LADG was associated with a significantly reduced rate of intra-operative blood loss, at the expense of significantly longer operating time and significantly reduced lymph node retrieval compared to its open counterpart. Mortality and tumour recurrence rates were similar between the two groups. Furthermore, time to commencement of oral intake, post procedural discharge from hospital and the perioperative complication rate although not significantly different between the two groups did suggest a positive trend toward LADG. Based on this meta-analysis, the authors cannot recommend the routine use of LADG over ODG for the treatment of distal gastric cancer. However, significant limitations exist in the interpretation of this data due to the limited number of published randomised control trials, the small sample sizes to date, and the limited duration of follow up. Further large multicentre randomised controlled trials are required to delineate significantly quantifiable differences between the two groups