Systematic Reviews
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Dec 14, 2015; 21(46): 13177-13187
Published online Dec 14, 2015. doi: 10.3748/wjg.v21.i46.13177
Endoscopy vs surgery in the treatment of early gastric cancer: Systematic review
André Kondo, Eduardo Guimarães Hourneaux de Moura, Wanderley Marques Bernardo, Osmar Kenji Yagi, Diogo Turiani Hourneaux de Moura, Eduardo Turiani Hourneaux de Moura, José Gonçalves Pereira Bravo, Kendi Yamazaki, Paulo Sakai
André Kondo, Eduardo Guimarães Hourneaux de Moura, Diogo Turiani Hourneaux de Moura, Eduardo Turiani Hourneaux de Moura, José Gonçalves Pereira Bravo, Kendi Yamazaki, Paulo Sakai, Gastrointestinal Endoscopy Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
Wanderley Marques Bernardo, Guidelines Program Coordinator, Brazilian Medical Association (AMB), Sao Paulo 01333-001, Brazil
Osmar Kenji Yagi, Gastrointestinal Surgery Division, Sao Paulo State Cancer Institute (ICESP), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 01255-000, Brazil
Author contributions: Kondo A did the electronic database search, revised and read all selected studies, analyzed all data and graphics, wrote the paper; de Moura EGH scientifically coordinated the study; Bernardo WM peer-reviewed the paper and scientifically coordinated the study (biostatistics and evidence-based guidance); Yagi OK translated the article in Japanese and carried out the analysis; de Moura DTH, de Moura ETH and Bravo JGP helped with data calculation and graphics creation; Yamazaki K helped with paper writing; Sakai P scientifically coordinated the study; all authors reviewed and approved the final manuscript as submitted.
Conflict-of-interest statement: All the authors declare that they have no competing interests.
Data sharing statement: The technical appendix, statistical code, and dataset are available from the corresponding author at andrekondo@gmail.com. No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: André Kondo, MD, Gastrointestinal Endoscopy Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil. andrekondo@gmail.com
Telephone: +55-11-26616467 Fax: +55-11-26616467
Received: May 27, 2015
Peer-review started: May 28, 2015
First decision: June 20, 2015
Revised: June 27, 2015
Accepted: September 14, 2015
Article in press: September 15, 2015
Published online: December 14, 2015
Abstract

AIM: To report a systematic review, establishing the available data to an unpublished 2a strength of evidence, better handling clinical practice.

METHODS: A systematic review was performed using MEDLINE, EMBASE, Cochrane, LILACS, Scopus and CINAHL databases. Information of the selected studies was extracted on characteristics of trial participants, inclusion and exclusion criteria, interventions (mainly, mucosal resection and submucosal dissection vs surgical approach) and outcomes (adverse events, different survival rates, mortality, recurrence and complete resection rates). To ascertain the validity of eligible studies, the risk of bias was measured using the Newcastle-Ottawa Quality Assessment Scale. The analysis of the absolute risk of the outcomes was performed using the software RevMan, by computing risk differences (RD) of dichotomous variables. Data on RD and 95%CIs for each outcome were calculated using the Mantel-Haenszel test and inconsistency was qualified and reported in χ2 and the Higgins method (I2). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled.

RESULTS: Eleven retrospective cohort studies were selected. The included records involved 2654 patients with early gastric cancer that filled the absolute or expanded indications for endoscopic resection. Three-year survival data were available for six studies (n = 1197). There were no risk differences (RD) after endoscopic and surgical treatment (RD = 0.01, 95%CI: -0.02-0.05, P = 0.51). Five-year survival data (n = 2310) showed no difference between the two groups (RD = 0.01, 95%CI: -0.01-0.03, P = 0.46). Recurrence data were analized in five studies (1331 patients) and there was no difference between the approaches (RD = 0.01, 95%CI: -0.00-0.02, P = 0.09). Adverse event data were identified in eight studies (n = 2439). A significant difference was detected (RD = -0.08, 95%CI: -0.10--0.05, P < 0.05), demonstrating better results with endoscopy. Mortality data were obtained in four studies (n = 1107). There was no difference between the groups (RD = -0.01, 95%CI: -0.02-0.00, P = 0.22).

CONCLUSION: Three-, 5-year survival, recurrence and mortality are similar for both groups. Considering complication, endoscopy is better and, analyzing complete resection data, it is worse than surgery.

Keywords: Gastric cancer, Endoscopy, Gastroscopy, Gastrectomy, Surgery, Systematic review

Core tip: As clinical and oncological outcomes of endoscopic resection of early gastric cancer compared to surgery have not been reported in systematic reviews, this study adds an important value to scientific literature, as it establishes and unifies data regarding this comparison. There are only retrospective cohort studies on this topic (2b evidence-level according to Oxford Centre). This review brings the information to an unpublished 2a strength of evidence, better handling nowadays clinical practice.