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Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma



The aim was to conduct a meta-analysis of the randomized evidence to determine the relative merits of laparoscopic assisted (LADG) and open (ODG) distal gastrectomy for proven gastric cancer.

Data sources and review methods

A search of the Medline, Embase, Science Citation Index, Current Contents, and PubMed databases identified all randomized clinical trials (RCTs) that compared LADG and OGD and were published in the English language between January 1990 and the end of June 2007. The meta-analysis was prepared in accordance with the Quality of Reporting of Meta-analyses (QUOROM) statement. The eight outcome variables analysed were operating time, blood loss, retrieval of lymph nodes, oral intake, hospital stay, postoperative complications, tumor recurrence, and mortality. Random effects meta-analyses were performed using odds ratios (OR) and weighted mean differences (WMD).


Four trials were considered suitable for meta-analysis. A total of 82 patients underwent LADG and 80 had ODG. For only one of the eight outcomes, the summary point estimates favoured LADG over ODG; there was a significant reduction of 104.26 ml in intraoperative blood loss for LADG (WMD, −104.26, 95% confidence interval (CI) −189.01 to −19.51; p = 0.0159). There was however a 83.08 min longer duration of operating time for the LADG group compared with the ODG group (WMD 83.08, 95% CI 40.53 to 125.64; p = 0.0001) and significant reduction in lymph nodes harvesting of 4.34 lymph nodes in the LADG group (WMD −4.3, 95% CI −6.66 to −2.02; p = 0.0002). Other outcome variables such as time to commencement of oral intake (WMD −0.97, 95% CI −2.47 to 0.54; p = 0.2068), duration of hospital stay (WMD −3.32, 95% CI −7.69 to 1.05; p = 0.1365), rate of complications (OR 0.66, 95% CI 0.27 to 1.60; p = 0.3530), mortality rates (OR 0.94, 95% CI 0.21 to 4.19; p = 0.9363), and tumor recurrence (OR 1.08, 95% CI 0.42 to 2.79; p = 0.8806) were not found to be statistically significant for either group. However, for commencement of oral intake, duration of hospital stay, and complication rate, the trend was in favor of LADG.


LADG was associated with a significantly reduced rate of intraoperative blood loss, at the expense of significantly longer operating time and significantly reduced lymph node retrieval compared to its open counterpart. Mortality and tumor recurrence rates were similar between the two groups. Furthermore, time to commencement of oral intake, postprocedural discharge from hospital, and perioperative complication rate, although not significantly different between the two groups, did suggest a positive trend toward LADG. Based on this meta-analysis, the authors cannot recommend the routine use of LADG over ODG for the treatment of distal gastric cancer. However, significant limitations exist in the interpretation of this data due to the limited number of published randomised control trials, the small sample sizes to date, and the limited duration of follow up. Further large multicentre randomized controlled trials are required to delineate significantly quantifiable differences between the two groups.

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  1. 1.

    Kitano S, Iso Y, Moriyama M (1994) Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc 4:146–8

    PubMed  CAS  Google Scholar 

  2. 2.

    Shehzad K, Mohiuddin K, Nizami S, Sharma H, Khan IM, Memon B, Memon MA (2007) Current status of minimal access surgery for gastric cancer. Surg Oncol 16:85–98

    PubMed  Article  Google Scholar 

  3. 3.

    Kajitani T (1981) The general rules for the gastric cancer study in surgery and pathology. Japanese research for gastric cancer. Jpn J Surg 11:127–139

    PubMed  Article  CAS  Google Scholar 

  4. 4.

    Japanese Gastric Cancer Association (2001) The guidelines for the treatment of gastric cancer. Kachara Co, Tokyo

    Google Scholar 

  5. 5.

    Maruyama K, Gunven P, Okabayashi K (1987) Lymph node metastases of gastric cancer: general pattern in 1931 patients. Ann Surg 210:596–602

    Google Scholar 

  6. 6.

    Maruyama K, Okabayashi K, Kinoshita T (1987) Progress in gastric cancer surgery in Japan in Japan and its limits of radicality. Word J Surg 11:418–425

    Article  CAS  Google Scholar 

  7. 7.

    Noguchi Y, Imada T, Matsumoto A (1986) Radical surgery for gastric cancer: a review of the Japanese experience. Cancer 64:2053–2062

    Article  Google Scholar 

  8. 8.

    Cuschieri A, Weeden S, Fieldig J (1999) Patient survival after D1 and D2 resections for gastric cancer: long term results of MRC randomized surgical trials. Br J Cancer 79:1522–1530

    PubMed  Article  CAS  Google Scholar 

  9. 9.

    Kitano S, Shiraishi N, Fujii K, Yasuda K, Inomata M, Adachi Y (2002) A randomized controlled trial comparing open vs laparoscopy-assisted distal gastrectomy for the treatment of early gastric cancer: an interim report. Surgery 131:S306–S311

    PubMed  Article  Google Scholar 

  10. 10.

    Huscher CGS, Mingoli A, Sgarzini G, Sansonetti A, Di Paola M, Rcher A, Ponzano C (2005) Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: five year results of a randomized prospective trial. Ann Surg 241:232–237

    PubMed  Article  Google Scholar 

  11. 11.

    Lee JH, Han HS, Lee JH (2005) A prospective randomized study comparing open vs laparoscopy-assisted distal gastrectomy in early gastric cancer: early results. Surg Endosc 19:168–173

    PubMed  Article  Google Scholar 

  12. 12.

    Hayashi H, Ochiai T, Shimada H, Gunji Y (2005) Prospective randomized study of open versus laparoscopy-assisted distal gastrectomy with extraperigastric lymph node dissection for early gastric cancer. Surg Endosc 19:1172–1176

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF (1999) Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of reporting of meta-analyses. Lancet 354:1896–1900

    PubMed  Article  CAS  Google Scholar 

  14. 14.

    Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17:1–12

    PubMed  Article  CAS  Google Scholar 

  15. 15.

    Agresti A (2002) Categorical data analysis, 2nd edn. Wiley, Canada, pp 1–734

    Google Scholar 

  16. 16.

    Sutton AJ, Abrams KR, Jones DR, Sheldon TA, Song F (2000) Methods for meta-analysis in medical research. Wiley, England, pp 1–346

    Google Scholar 

  17. 17.

    Egger M, Smith GD, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. Br Med J 315:629–634

    CAS  Google Scholar 

  18. 18.

    Tang JL, Liu JLY (2000) Misleading funnel plot for detection of bias in meta-analysis. J Clin Epidemiol 53:477–484

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Span J, Carière E, Croockewitt S, Smits P (2006) Publication bias, effects on the assessment of Rosiglitasone. Proc Dutch Soc Clin Pharmacol Biopharm Meet, April 2006. Br J Clin Pharmacol 62:732

    Google Scholar 

  20. 20.

    Hornik K. The R FAQ. Version 2.6.2007-10-22. ISBN 3-900051-08-9. Accessed 16 February 2008

  21. 21.

    Solomon MJ, Laxamana A, Devore L, McLeod RS (1994) Randomized controlled trials in surgery. Surgery 115:707–712

    PubMed  CAS  Google Scholar 

  22. 22.

    McLeod RS, Wright JG, Solomon MJ, Hu X, Walters BC. Lossing A (1996) Randomized controlled trials in surgery: issues and problems. Surgery 119:483–486

    PubMed  Article  CAS  Google Scholar 

  23. 23.

    Horton R (1996) Surgical research or comic opera: questions, but few answers. Lancet 347:984–985

    PubMed  Article  CAS  Google Scholar 

  24. 24.

    Sutton AJ, Abrams KR, Jones DR, Sheldon TA, Song F (2000) Methods for meta-analysis in medical research. Wiley, Chichester

    Google Scholar 

  25. 25.

    Dellinger EP, Anaya DA (2004) Infectious and immunologic consequences of blood transfusion. Crit Care 8 Suppl 2:S18–S23

    Google Scholar 

  26. 26.

    Vamvakas EC (1995) Perioperative blood transfusion and cancer recurrence: meta-analysis for explanation. Transfusion 35:760–768

    PubMed  Article  CAS  Google Scholar 

  27. 27.

    Forbes JM, Anderson MD, Anderson GF, Bleecker GC, Rossi EC, Moss GS (1991) Blood transfusion costs: a multicenter study. Transfusion 31:318–323

    PubMed  Article  CAS  Google Scholar 

  28. 28.

    Danielson H, Kokkola A, Kiviluoto T, Siren J, Louhimo J, Kivilaakso E, Puolakkainen P (2007) Clinical outcome afer D1 vs D2-3 gastrectomy for treatment of gastric cancer. Scand J Surg 96:35–40

    PubMed  CAS  Google Scholar 

  29. 29.

    Sano T, Sasako M, Yamamoto S, Nashimoto A, Kurita A, Hiratsuka M, Tsujinaka T, Kinoshita T, Arai K, Yamamura Y, Okajima K (2004) Gastric cancer surgery: morbidity and mortality resuls from a prospective randomized controlled trial comparing D2 and extended paraaortic lymphadenectomy – Japan Clinical Oncology Group study 9501. J Clin Oncol 22:2767–2773

    PubMed  Article  Google Scholar 

  30. 30.

    Bonenkamp JJ, Hermans J, Sasako M, van de Velde CJ, Welvaart K, Songun I, Meyer S, Plukker JT, Van Elk P, Obertp H, Gouma DJ, van Lanschot JJ, Taat CW, de Graaf PW, von Meyenfeldt MF, Tilanus H, Dutch Gastric Cancer Group (1999) Extended lymph-node dissection for gastric cancer. N Engl J Med 340:908–914

    Google Scholar 

  31. 31.

    McCulloch P, Nita ME, Kazi H, Gama-Rodrigues J (2004) Extended versus limited lymph nodes dissection technique for adenocarcinoma of the stomach. Cochrane Database Syst Rev 18:CD001964

    Google Scholar 

  32. 32.

    Miura S, Kodera Y, Fujiwara M, Ito S, Mochizuki Y, Yamamura Y, Hibi K, Ito K, Akiyama S, Nakao A (2004) Laparoscopy-assisted distal gastrectomy with systemic lymph node dissection: a critical reappraisal from the viewpoint of lymph node retrieval. J Am Coll Surg 198:933–938

    PubMed  Article  Google Scholar 

  33. 33.

    Schauer PR, Luna J, Ghiatas AA, Glen ME, Warren JM, Sirinek KR (1993) Pulmonary function after laparoscopic cholecystectomy. Surgery 114:389–399

    PubMed  CAS  Google Scholar 

  34. 34.

    McMahon AJ, Baxter JN, Kenney G, O’Dwyer PJ (1993) Ventilatory and blood gas change during laparoscopic and open cholecystectomy. Br J Surg 80:1252–1254

    PubMed  Article  CAS  Google Scholar 

  35. 35.

    Frazee RC, Roberts JW, Okeson GC, Symmonds RE, Snyder SK, Hendricks JC, Smith RW (1991) Open versus laparoscopic cholecystectomy: a comparison of postoperative pulmonary function. Ann Surg 213:651–654

    PubMed  CAS  Article  Google Scholar 

  36. 36.

    Schwenk W, Bohm B, Muller JM (1998) Postoperative pain and fatigue after laparoscopic or conventional colorectal resections: a prospective randomized trial. Surg Endosc 12:1131–1136

    PubMed  Article  CAS  Google Scholar 

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Authors’ contributions: MAM was responsible for the concept and design of this meta-analysis. Furthermore he takes responsibility for the integrity of the work as a whole, from inception to published article. MAM, RB and BM were responsible for acquisition and interpretation of the data. SK and RMY were involved in analyzing and interpretation of the data in depth from the statistical point of view.

All authors were involved in drafting the manuscript and revising it critically for important intellectual content and have given final approval of the version to be published. Furthermore all authors have participated sufficiently in the work to take public responsibility for its content.

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Correspondence to Muhammed Ashraf Memon.

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Memon, M.A., Khan, S., Yunus, R.M. et al. Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma. Surg Endosc 22, 1781–1789 (2008).

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  • Gastric cancer
  • Gastrectomy
  • Laparoscopic method
  • Comparative studies
  • Meta-analysis
  • Randomized controlled trials
  • Patient outcome
  • Intraoperative complications
  • Postoperative complications
  • Hospitalization
  • Human