Laparoscopic assisted distal gastrectomy for early gastric cancer: Is it an alternative to the open approach?

Abstract

Objective

This study aims to compare short term outcomes and oncological value of laparoscopy assisted (LADG) and open distal gastrectomy (ODG) in the treatment of early gastric cancer.

Methods

Meta-analysis of 12 studies, including three randomized controlled trials, published between 2000 and 2007, comparing laparoscopy assisted and open distal gastrectomy in 951 patients with early gastric cancer, was done. Outcomes of interest were operative data, lymph node clearance, postoperative recovery complications.

Results

Overall morbidity rate was significantly less with LADG (10.5% versus 20.1%, P = 0.003, OR 0.52, CI 0.34–0.8). A mean of 4.61 less number of lymph nodes dissected than ODG (CI −5.96, −3.26 P < 0.001) when all studies are included. There was no difference between the two groups in number of lymph nodes dissected when less than D2 lymphadenectomy was done (2.44 nodes less in LADG group, CI −5.52, 0.63; P = 0.12). LADG patients had less operative blood loss (mean of 151 ml, P < 0.001), less time to walking, oral intake and flatus. LADG patients had less length of hospital stay (5.7 days, P < 0.001), postoperative fever and pain. ODG group showed significantly less operative time. There was no significant difference between the two groups in the incidence of anastomotic complications and wound infection.

Conclusion

LADG is a safe technical alternative to ODG for early gastric cancer with a lower overall complication rate and enhanced postoperative recovery. Endorsing LADG as a better alternative to ODG requires data on long term survival, quality of life and cost effectiveness.

Introduction

Laparoscopic assisted distal gastrectomy (LADG) has been proved to be a feasible technical option in the treatment of gastric cancer [1], [2], [3], [4], [5], [6]. Nevertheless, there is no general consensus among gastric surgeons on the best approach for routine clinical practice in early gastric cancer. Proponents of LADG adopt it due to advantages commonly attributed to minimal access approaches as less operative blood loss, pain, earlier recovery of bowel activity and a shorter hospital stay [1], [2], [4], [6], [7], [8], [9]. However, this approach is technically demanding in complex cancer surgery and its adequacy for lymph node clearance is still controversial [10]. In contrast to gold standard laparoscopic procedures such as cholecystectomy and fundoplication where the trauma of the access is more than that of dissection, in laparoscopic gastrectomy for cancer the trauma of gastric resection and lymphadenectomy outweighs the trauma of the access and hence the uncertainty of the influence of reduction of overall trauma on postoperative recovery.

Early gastric cancer patients would potentially benefit from the laparoscopic approach since a conservative resection has been recently recommended by the Japan Gastric Cancer Association (JGCA) for these patients [11]. Also, open distal gastrectomy (ODG) is relatively a safe and technically less demanding procedure than total gastrectomy. Although there are several clinical reports comparing the results of laparoscopic assisted distal gastrectomy and conventional open distal gastrectomy for early gastric cancer patients, conclusions were difficult to be drawn due to small study sizes. A recent meta-analysis [12] on short term outcomes comparing LADG and ODG was published, yet there are a few remarks undermining the validity of results as: (a) it included patients with advanced gastric cancer; (b) it included studies where different laparoscopic techniques were used; (c) the focus was on morbidity rather than lymph node clearance; (d) No test for publication bias was done; and (e) heterogeneity was not explained and a trial to overcome it was not done. Those factors are crucial in determining the outcome of surgical interventions. This communication aims to compare between LADG and ODG with emphasis on the oncological value and as well report on short and long term outcomes of LADG and ODG for a homogenous group of early gastric cancer patients.