Totally laparoscopic gastrectomy for gastric cancer: A systematic review and meta-analysis of outcomes compared with open surgery

doi:10.3748/wjg.v20.i42.15867

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World Journal of Gastroenterology

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Meta-Analysis

World J Gastroenterol. Nov 14, 2014; 20(42): 15867-15878
Published online Nov 14, 2014. doi: 10.3748/wjg.v20.i42.15867

Table 1 Summary of studies included in the meta-analysis

Ref.	Region	Study design	Year	Study period	Sample size		Level of lymphad-enectomy	Surgical extension	Reconstruction	Conversion	Mortality		Matched factors¹	Quality scores
Ref.	Region	Study design	Year	Study period	TLG	OG	Level of lymphad-enectomy	Surgical extension	Reconstruction	Conversion	TLG	OG	Matched factors¹	Quality scores
Huscher et al[25]	Italy	RCT	2005	1992-1996	30	29	D1, D2	D	B-II, R-Y	NR	3.3%	6.7%	-	3²
Pugliese et al[26]	Italy	OCS (R)	2007	2000-2005	48	99	D2	S, T	R-Y	2.1%	2.1%	3.0%	-	7
Song et al[27]	South Korea	OCS (P)	2008	2005-2006	20	20	D1 + β, D2	D	B-I, R-Y	0	0	0	-	8
Lee et al[28]	Taiwan	OCS (P)	2008	1998-2005	34	34	D2	S	B-II	2.9%	0	0	1245	9
Topal et al[29]	Belgium	OCS (R)	2008	2003-2006	38	22	D2	T	R-Y	NR	2.6%	4.5%	-	8
Strong et al[30]	United States	OCS (P)	2009	2005-2008	30	30	D2	S	B-II, R-Y	NR	0	0	1245	9
Wong et al[31]	Hong Kong	OCS (R)	2009	2001-2006	18	41	D1 + α/β, D2	D	B-II, R-Y	5.0%	0	2.4%	-	7
Chouillard et al[32]	France	OCS (P)	2010	2001-2007	51	79	D2	D, T	B-II, R-Y	6.0%	0	2.5%	-	9
Scatizzi et al[33]	Italy	OCS (P)	2011	2006-2009	30	30	D2	D	R-Y	6.7%	0	0	12345	9
Moisan et al[34]	Chile	OCS (R)	2012	2005-2010	31	31	D1 + α/β, D2	S, T	B-II, R-Y	3.2%	0	0	1245	9
Cianchi et al[35]	Italy	OCS (P)	2012	2008-2012	41	41	D1 + α/β, D2	S, T	B-II, R-Y	0	2.4%	4.9%	1245	8
Siani et al[36]	Italy	OCS (R)	2012	2003-2009	25	25	D1 + α/β, D2	T	R-Y	0	0	0	145	9
Shinohara et al[37]	Japan	OCS (P)	2013	1998-2008	186	123	D2	D, P, T	B-I, R-Y	2.2%	1.1%	0	12345	9
Kim et al[38]	South Korea	OCS (P)	2013	2011	139	207	D2	T	R-Y	0	0	0	-	7

¹Jadad scores;

²Factors matched between groups: 1: Age; 2: Sex; 3: Body mass index; 4: Stage; 5: Type of gastrectomy. RCT: Randomized controlled trial; OCS: Observational clinical study; P: Prospectively collected data; R: Retrospectively collected data; TLG: Totally laparoscopic gastrectomy; OG: Open gastrectomy; D: Distal gastrectomy; P: Proximal gastrectomy; T: Total gastrectomy; S: Subtotal gastrectomy; B-I: Billroth-I; B-II: Billroth-II; R-Y: Roux-en-Y; NR: Not reported.

Table 2 Outcomes of included studies

Ref.	Operation time	Blood loss	Transfusion	RLN	Proximal margin	Distal margin	Analgesic use	Ambulation	Flatus	Oral intake	Hospital stay	Morbidity	Mortality	Survival
Huscher et al[25]	Y	Y		Y						Y	Y	Y	Y	Y
Pugliese et al[26]	Y	Y		Y			Y¹	Y	Y	Y	Y	Y	Y
Song et al[27]	Y	Y		Y	Y	Y	Y²		Y	Y	Y	Y	Y
Lee et al[28]	Y	Y		Y			Y²		Y		Y	Y	Y
Topal et al[29]	Y	Y										Y	Y
Strong et al[30]	Y	Y		Y			Y¹				Y	Y	Y	Y
Wong et al[31]	Y	Y		Y							Y	Y	Y	Y
Chouillard et al[32]	Y	Y	Y	Y							Y	Y	Y	Y
Scatizzi et al[33]	Y			Y			Y¹	Y	Y	Y	Y	Y	Y	Y
Moisan et al[34]	Y	Y	Y	Y		Y				Y	Y	Y	Y	Y
Cianchi et al[35]	Y	Y		Y					Y	Y	Y	Y	Y
Siani et al[36]	Y	Y		Y					Y		Y	Y	Y	Y
Shinohara et al[37]	Y	Y	Y	Y				Y		Y	Y	Y	Y	Y
Kim et al[38]	Y			Y	Y	Y	Y²		Y	Y	Y	Y	Y

¹Reported days of analgesic use;

²Reported days and amount of analgesic use. Y: Yes; RLN: Retrieved lymph nodes.

Table 3 Pooled short-term outcomes

Outcomes	No. of studies	Sample size		Heterogeneity	Overall effect size	95%CI of overall effect	P value
Outcomes	No. of studies	TLG	OG	(P value, I²)	Overall effect size	95%CI of overall effect	P value
Operation time (min)	14	721	811	< 0.001, 97%	WMD = 58.04	37.77-78.32	< 0.001
Blood loss (mL)	12	552	574	< 0.001, 87%	WMD = -167.57	-208.79-(-126.34)	< 0.001
Transfusion	3	268	233	0.11, 54%	RR = 0.49	0.21-1.11	0.09
Retrieved lymph nodes	13	683	789	0.04, 46%	WMD = -0.48	-2.21-1.26	0.59
Proximal margin (cm)	2	159	227	0.03, 80%	WMD = 0.00	-1.47-1.46	1.00
Distal margin (cm)	3	190	258	0.03, 70%	WMD = 0.94	-0.76-(2.64)	0.28
Analgesics given (d)	3	108	159	0.33, 11%	WMD = -1.79	-2.37-(-1.21)	< 0.001
Time to ambulation (d)	3	264	252	< 0.001, 93%	WMD = -0.91	-1.65-(-0.16)	0.02
Time to first flatus (d)	7	337	456	< 0.001, 98%	WMD = -1.97	-3.18-(-0.77)	0.001
Time to oral intake (d)	8	525	580	< 0.001, 96%	WMD = -2.39	-3.34-(-1.45)	< 0.001
Hospital stay (d)	13	683	789	< 0.001, 83%	WMD = -3.75	-4.88-(-2.63)	< 0.001
Overall complications	14	721	811	0.74, 0%	RR = 0.71	0.58-0.86	< 0.001
Surgical complications	12	635	690	0.76, 0%	RR = 0.75	0.57-0.98	0.03
Medical complications	11	615	670	0.97, 5%	RR = 0.57	0.38-0.86	0.008
Mortality	7	412	434	0.96, 0%	RR = 0.65	0.24-1.76	0.40

WMD: Weighted mean difference; RR: Risk ratio; TLG: Totally laparoscopic gastrectomy; OG: Open gastrectomy.

Table 4 Subgroup analysis of learning curve using a cut-point of 40 totally laparoscopic gastrectomy cases

Outcomes	No. of studies	Sample size		Heterogeneity	Overall effect size	95%CI of overall effect	P value
Outcomes	No. of studies	TLG	OG	(P value, I²)	Overall effect size	95%CI of overall effect	P value
Operation time (min)
< 40 TLG cases	9	256	262	< 0.001, 92%	WMD = 60.54	35.64-85.45	< 0.001
> 40 TLG cases	5	465	549	< 0.001, 99%	WMD = 53.91	16.74-91.08	0.004
Blood loss (mL)
< 40 TLG cases	8	226	232	< 0.001, 84%	WMD = -155.04	-133.22	< 0.001
> 40 TLG cases	4	326	342	< 0.001, 85%	WMD = -194.81	-95.98	< 0.001
Retrieved lymph nodes
< 40 TLG cases	8	218	240	0.23, 25%	WMD = -1.41	-6.11	0.37
> 40 TLG cases	5	465	549	0.06, 63%	WMD = 0.03	-4.27	0.98

TLG: Totally laparoscopic gastrectomy; OG: Open gastrectomy; WMD: Weighted mean difference.

Table 5 Systematic review of postoperative complications and reoperation n (%)

Ref.	Group	n	Total events	Leakage	Stenosis	Pulmonary	Wound	Pancreatitis	Obstruction	Cardiovascular	Bleeding	Abscess	Other	Reoperation
Huscher et al[25]	TLG	30	7			4	2	1						NR
Huscher et al[25]	OG	29	8	1		5	2							NR
Pugliese et al[26]	TLG	48	61	2		3								NR
Pugliese et al[26]	OG	99	141	3										NR
Song et al[27]	TLG	20	1								1			0
Song et al[27]	OG	20	1					1						0
Lee et al[28]	TLG	34	7	1			1		3		1	1		2
Lee et al[28]	OG	34	6	2		1	2		1					0
Topal et al[29]	TLG	38	151	2		1		1	3					6
Topal et al[29]	OG	22	91											0
Strong et al[30]	TLG	30	8	1			1	1	3	1	1			NR
Strong et al[30]	OG	30	13	1		1	3		4	1		2	1	NR
Wong et al[31]	TLG	18	3	1			1					1		NR
Wong et al[31]	OG	41	8	3		2			1		1	1		NR
Chouillard et al[32]	TLG	51	91	2
Chouillard et al[32]	OG	79	201	4
Scatizzi et al[33]	TLG	30	2	2										1
Scatizzi et al[33]	OG	30	8	1		3				1	1		2	1
Moisan et al[34]	TLG	31	7	4		1					1		1	4
Moisan et al[34]	OG	31	4	2									2	4
Cianchi et al[35]	TLG	41	9	2	1	1		2		1	1		1	3
Cianchi et al[35]	OG	41	14	4		5			1	2			2	2
Siani et al[36]	TLG	25	4	1		1							2	NR
Siani et al[36]	OG	25	5			2	2			1				NR
Shinohara et al[37]	TLG	186	441	5	4		2	12				9		8
Shinohara et al[37]	OG	123	431	5	5		10	8				9		2
Kim et al[38]	TLG	139	14	1	2	2	1		3		3		2	5
Kim et al[38]	OG	207	45	1	4	9	12		2		2	11	4	NR
Total (%)	TLG	721	136	24 (3.4)	7 (1.9)	13 (2.8)	8 (1.7)	17 (4.5)	12 (4.0)	2 (1.6)	8 (2.3)	11 (2.7)	6 (2.0)
Total (%)	OG	811	198	27 (3.4)	9 (2.4)	28 (4.8)	31 (6.3)	9 (3.0)	9 (2.4)	5 (4.0)	4 (0.9)	23 (5.3)	11 (3.0)
P value				0.99	0.63	0.003	< 0.001	0.32	0.23	0.45	0.11	0.06	0.42

¹Some complications were not speciﬁed. NR: Not reported; TLG: Totally laparoscopic gastrectomy; OG: Open gastrectomy.

Table 6 Systematic review of long-term survival

Ref.	Group	Follow-up (mo)	Recurrence	Survival rate (%)
Huscher et al[25]	TLG	60 (2-88)	11	5-yr DFS: 57.3, 5-yr OS: 58.9
Huscher et al[25]	OG	55 (7-90)	10	5-yr DFS: 54.8, 5-yr OS: 55.7
Lee et al[28]	TLG	NR¹	2	NR
Lee et al[28]	OG	NR¹	1	NR
Song et al[27]	TLG	11	4	NR²
Song et al[27]	OG	13.8	5	NR²
Wong et al[31]	TLG	32 (2-79)	2	5-yr OS: 81.0
Wong et al[31]	OG	27 (1-79)	9	5-yr OS: 67.5
Chouillard et al[32]	TLG	29 (12-74)	NR	OS, 1-yr: 88.4, 2-yr: 71.2, 3-y: 43.2
Chouillard et al[32]	OG	33 (14-79)	NR	OS, 1-yr: 88.3, 2-yr: 54.8, 3-yr: 38.4
Scatizzi et al[33]	TLG	18 (2-37)	NR	42-mo OS: 70.9
Scatizzi et al[33]	OG	18 (7-42)	NR	42-mo OS: 56.8
Moisan et al[34]	TLG	28	5	3-yr DFS: 79.4, 3-yr OS: 82.3
Moisan et al[34]	OG	40	4	3-yr DFS: 83.4, 3-yr OS: 86.9
Siani et al[36]	TLG	32.6	NR	5-yr DFS: 54.2, 5-yr OS: 55.7
Siani et al[36]	OG	31.9	NR	5-yr DFS: 52.1, 5-yr OS: 52.9
Shinohara et al[37]	TLG	48.8(25-58.5)^a	53	5-yr DFS: 65.8^b, 5-yr OS: 68.1^b
Shinohara et al[37]	OG	48.8(25-58.5)^a	34	5-yr DFS: 62.0^b, 5-yr OS: 63.7^b

¹All patients were followed up for at least 2 years;

²DFS at 36 mo demonstrated no signiﬁcant difference between the groups. Follow-up time was shown as median (range); a: Shown as interquartile range; b: Calculated by excluding stage IA and missed follow-up patients. DFS: Disease-free survival; OS: Overall survival; NR: Not reported.

Citation: Chen K, Pan Y, Cai JQ, Xu XW, Wu D, Mou YP. Totally laparoscopic gastrectomy for gastric cancer: A systematic review and meta-analysis of outcomes compared with open surgery. World J Gastroenterol 2014; 20(42): 15867-15878
URL: https://www.wjgnet.com/1007-9327/full/v20/i42/15867.htm
DOI: https://dx.doi.org/10.3748/wjg.v20.i42.15867