Reevaluation of laparoscopic versus open distal gastrectomy for early gastric cancer in Asia: A meta-analysis of randomized controlled trials

Background: The benefits and risks of laparoscopic distal gastrectomy (LADG) are not yet sufficiently clear for acceptance as a standard treatment of early gastric cancer. Previous meta-analyses were not powered to reach definitive conclusions. Materials and Methods: Randomized controlled trials comparing LADG with open distal gastrectomy (ODG) for early gastric cancer in Asia and published between January 1994 and January 2018 were retrieved from PubMed, Embase, the Cochrane Library, and Google Scholar. Patient characteristics, oncological safety and efficacy, and surgical safety were evaluated following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Grading of Recommendations Assessment, Development and Evaluation guidelines (GRADE) guidelines. Trial Sequential Analysis (TSA) reduced random error and reinforced the reliability and strength of evidence. Results: Eight trials including 2666 participants were selected. LADG benefits were an 11.6 cm shorter incision (95% CI: -13.31 to -9.88 cm; P < 0.0001), 103.81 ml less blood loss (95% CI: -133.68 to -73.94; P < 0.0001), 1.73 times less analgesic use (95% CI: -2.21 to -1.24; P < 0.0001), 0.51 days shorter time to first flatus (95% CI: -0.88 to -0.15 days; P=0.006), lower risk of wound dehiscence (RR=0.24, 95% CI: 0.08-0.78; P=0.02), lower risk of surgical adverse events (RR=0.69, 95% CI: 0.53-0.91; P=0.008), and lower risk of respiratory complications (RR=0.40; 95% CI: 0.20-0.79; P=0.009) than ODG. LADG had 2.22 fewer resected lymph nodes (95% CI: -4.33 to -0.12; P=0.04) and 76.61 min longer procedures (76.61 min, 95% CI: 57.74-95.47 min; P < 0.0001). Conclusions: In Asian patients, LADG had similar mortality and oncological safety, better surgical safety, less operative morbidity, less trauma, and faster recovery than ODG. It has a high role to play in node-negative cases due to better short-term outcomes but less nodal harvest. It is a recommended alternative treatment for experienced surgeons in high-volume centers.