Minimally Invasive Versus Open Total Gastrectomy f

Authors: Jennifer Straatman Nicole van der Wielen Miguel A Cuesta Elly S M de Lange – de Klerk Elise P Jansma Donald L van der Peet

Publish Date: 2015/09/08

Volume: 40, Issue: 1, Pages: 148-157

PDF Link

Abstract

Minimally invasive surgical techniques for gastric cancer are gaining more acceptance worldwide as an alternative to open resection In order to assess the role of minimally invasive and open techniques in total gastrectomy for cancer a systematic review and metaanalysis was performed Articles comparing minimally invasive versus open total gastrectomy were reviewed collected from the Medline Embase and Cochrane databases Two different authors JS and NW independently selected and assessed the articles Outcomes regarding operative results postoperative recovery morbidity mortality and oncological outcomes were analyzed Statistical analysis portrayed the weighted mean difference WMD with a 95  confidence interval and odds ratio OR Out of 1242 papers 12 studies were selected including a total of 1360 patients of which 592 underwent minimally invasive total gastrectomy MITG Compared to open total gastrectomy OTG MITG showed a longer operation time WMD 4806 min P  000001 less operative blood loss WMD −16070 mL P  000001 faster postoperative recovery measured as shorter time to first flatus WMD −105 days P  000001 shorter length of hospital stay WMD −243 days P = 00002 less postoperative complications OR 066 P = 002 similar mortality rates OR 060 P = 052 and similar rates in lymph node yield WMD −230 P = 006 Minimally invasive total gastrectomy showed faster postoperative recovery and less postoperative complications whereas completeness of the resection was similar in both groups Duration of surgery was longer in the minimally invasive group Only comparative nonrandomized studies were available further emphasizing the need for a prospective randomized trial comparing MITG and OTGGastric cancer is responsible for ten per cent of all cancerrelated deaths worldwide with the highest incidence rates in Eastern Asia Eastern Europe and South America 1 Until this day the only curative treatment for gastric cancer is gastrectomy with adequate lymph node dissection 2 As neoadjuvant therapy has proven to be successful an increasing number of patients are treated this way 3 4 In recent years minimally invasive techniques have gained increasing interest in the treatment of gastric cancer The first reported minimally invasive distal gastrectomy was performed in 1994 by Kitano et al 5 followed in 1996 by the first minimally invasive total gastrectomy for cancer by Azagra et al 6 Since then several studies and metaanalyses examined the safety and feasibility of minimally invasive gastrectomy for cancer 7 8 9 The outcomes of these studies have shown promising results such as faster recovery less pain shorter hospital stay improved quality of life after surgery and above all equal outcomes of morbidity and mortality in comparison with open gastrectomy 10 Although the results are promising the number of studies was relatively small their power was low and no difference was made between types of gastrectomy but mainly focused on distal gastrectomy or combined the different types of gastrectomies partial total and/or proximal 9 10 11 Consequently a heterogeneous study population was created and as a result outcomes are not transferable to an actual group of total gastrectomy patients 7 12 13The aim of this study is to assess evidence for a minimally invasive approach in total gastrectomy by comparing MITG to OTG with respect to operative data conversion rate postoperative data morbidity and mortality completeness of surgical resection postoperative recovery and longterm outcomesTo identify all relevant publications a systematic search in the bibliographic databases PubMed EMBASE and The Cochrane Library via Wiley from inception to February 5th 2015 was performed Search terms included controlled terms from MeSH in PubMed EMtree in EMBASEcom as well as free text terms Free text terms were only used in The Cochrane library Search terms expressing ‘stomach neoplasms’ were used in combination with search terms comprising ‘open surgery’ and ‘laparoscopy’ The reference list of included articles was handsearched for relevant publicationsTwo authors JS and NW independently evaluated the search findings for potential eligibility for this metaanalysis using the Medline Embase and Cochrane databases The inclusion criteria were as follows 1 Article published in English language 2 Only fulltext articles no abstracts or case reports were included and 3 The study had to compare minimally invasive total gastrectomy MITG with open total gastrectomy OTG for cancerOperation duration was defined in minutes and blood loss in milliliters All studies reporting blood loss in grams were not included in the analysis of this parameter Hospital stay and time to first flatus were reported in days If studies reported these parameters in hours a conversion to days would be made Definitions of complications varied between different studies and there was no consensus in reporting type or grade of complication such as the ClavienDindo grading system for the classification of surgical complications 14 15 Therefore only the number of complications was reported Inhospital mortality was defined as mortality within 30 days after surgery Lymph node yield was measured as the mean number of resected lymph nodes with a standard deviation Data regarding mean resection margins were also collected along with survival data None of the studies reported neoadjuvant treatmentThe reviewers JS and NW extracted the following data from each study first author title of the article year of publication geographical region type of study type of gastrectomy type of reconstruction TNM stage number of patients included number of patients who underwent open gastrectomy number of patients who underwent minimally invasive gastrectomy operation duration estimated blood loss time to first flatus time to first oral intake length of hospital stay percentage of postoperative complications and percentage of mortality Moreover data concerning followup and survival were collected All the data were reported in means and standard deviation If the article did not report the parameters in means and standard deviations a request for this information was sent to the concerning author and this information was received from one author 16 Due to the difficulty of receiving raw data the data from the published articles were used in this metaanalysis To assess the quality of the studies all reviewers classified the studies using the NewcastleOttawa Quality Assessment Scale NOS for retrospective cohort studies and case–control studies 17 A maximum of nine points could be awarded four points for selection criteria two points for comparability and three points for outcome Beforehand the criteria were discussed between the reviewers so an equal scoring method was used In case of doubt deliberation was conducted between the reviewers and the problem would be resolved with mutual approval Studies achieving six or more points would be classified as high quality and were used for further analysis Moreover the level of evidence was assessed for each study 18The metaanalysis was performed in line with the recommendations from the PRISMA Statement for Reporting Systematic Reviews and MetaAnalyses 19 Review Manager version 533 2014 was used for data analyses as downloaded from the Cochrane Library Continuous variables were assessed using the weighted mean difference Dichotomous variables were assessed using the Odds Ratio To account for clinical heterogeneity the random effects model based on DerSimonian and Laird’s method was used P value 005 was considered statistically significant

Keywords: