Laparoscopic versus open gastrectomy for gastric cancer

Lawrence MJ Best; Muntzer Mughal; Kurinchi Selvan Gurusamy

doi:10.1002/14651858.CD011389.pub2

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Figure 1

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Study flow diagram.

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Analysis 1.1

Comparison 1 Laparoscopic versus open gastrectomy, Outcome 1 Short‐term mortality.

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Analysis 1.2

Comparison 1 Laparoscopic versus open gastrectomy, Outcome 2 Long‐term mortality (maximal follow‐up).

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Analysis 1.3

Comparison 1 Laparoscopic versus open gastrectomy, Outcome 3 Proportion with a serious adverse event (< 3 months).

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Analysis 1.4

Comparison 1 Laparoscopic versus open gastrectomy, Outcome 4 Short‐term recurrence.

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Analysis 1.5

Comparison 1 Laparoscopic versus open gastrectomy, Outcome 5 Long‐term recurrence (maximal follow‐up).

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Analysis 1.6

Comparison 1 Laparoscopic versus open gastrectomy, Outcome 6 Proportion with an adverse event (< 3 months).

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Analysis 1.7

Comparison 1 Laparoscopic versus open gastrectomy, Outcome 7 Proportion requiring blood transfusion during or within a week of surgery.

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Analysis 1.8

Comparison 1 Laparoscopic versus open gastrectomy, Outcome 8 Quantity of perioperative blood transfused.

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Analysis 1.9

Comparison 1 Laparoscopic versus open gastrectomy, Outcome 9 Length of hospital stay.

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Analysis 1.10

Comparison 1 Laparoscopic versus open gastrectomy, Outcome 10 Proportion with positive resection margins at histopathological examination.

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Analysis 1.11

Comparison 1 Laparoscopic versus open gastrectomy, Outcome 11 Number of lymph nodes harvested.

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Analysis 2.1

Comparison 2 Laparoscopic versus open gastrectomy (subgroup analysis), Outcome 1 Short‐term mortality (stratified by early versus advanced cancer).

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Analysis 2.2

Comparison 2 Laparoscopic versus open gastrectomy (subgroup analysis), Outcome 2 Long‐term mortality (maximal follow‐up) (stratified by early versus advanced cancer).

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Analysis 2.3

Comparison 2 Laparoscopic versus open gastrectomy (subgroup analysis), Outcome 3 Proportion with a serious adverse event (< 3 months) (stratified by early versus advanced cancer).

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Analysis 2.4

Comparison 2 Laparoscopic versus open gastrectomy (subgroup analysis), Outcome 4 Short‐term mortality (stratified by type of gastrectomy).

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Analysis 2.5

Comparison 2 Laparoscopic versus open gastrectomy (subgroup analysis), Outcome 5 Long‐term mortality (maximal follow‐up) (stratified by type of gastrectomy).

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Analysis 2.6

Comparison 2 Laparoscopic versus open gastrectomy (subgroup analysis), Outcome 6 Proportion with a serious adverse event (< 3 months) (stratified by type of gastrectomy).

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Summary of findings for the main comparison. Laparoscopic gastrectomy compared to open gastrectomy for gastric cancer (primary outcomes)

Laparoscopic gastrectomy compared to open gastrectomy for gastric cancer (primary outcomes)
Patient or population: patients with gastric cancer Settings: secondary or tertiary setting Intervention: laparoscopic gastrectomy Comparison: open gastrectomy
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)
	Assumed risk	Corresponding risk
	Open gastrectomy	Laparoscopic gastrectomy
Short‐term mortality	3 per 1000	6 per 1000 (2 to 18)	RR 1.60 (0.50 to 5.10)	2335 (11 studies)	⊕⊕⊝⊝ low¹
Long‐term mortality (maximal follow‐up)	448 per 1000	428 per 1000 (340 to 524)	HR 0.94 (0.70 to 1.25)	195 (3 studies)	⊕⊝⊝⊝ very low^1,2
Proportion with a serious adverse event (< 3 months)	60 per 1000	36 per 1000 (16 to 81)	RR 0.60 (0.27 to 1.34)	432 (8 studies)	⊕⊝⊝⊝ very low^1,2
Health‐related quality of life during short‐term (four weeks to three months) or medium‐term (more than three months to one year) was not reported.
The basis for the assumed risk* was the mean control group proportion. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; HR: hazard ratio; RR: risk ratio.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ There was unclear or high risk bias within the trials (downgraded by two levels). ² The confidence intervals were wide (overlaps no effect and clinically significantly effect) and the sample size was small (downgraded by two levels).

Summary of findings for the main comparison. Laparoscopic gastrectomy compared to open gastrectomy for gastric cancer (primary outcomes)

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Summary of findings 2. Laparoscopic gastrectomy compared to open gastrectomy for gastric cancer (secondary outcomes)

Laparoscopic gastrectomy compared to open gastrectomy for gastric cancer (secondary outcomes)
Patient or population: patients with gastric cancer Settings: secondary or tertiary setting Intervention: laparoscopic gastrectomy Comparison: open gastrectomy
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Open gastrectomy	Laparoscopic gastrectomy
Long‐term recurrence (maximal follow‐up)	450 per 1000	433 per 1000 (342 to 540)	HR 0.95 (0.70 to 1.30)	162 (4 studies)	⊕⊝⊝⊝ very low^1,2
Proportion with an adverse event (< 3 months)	207 per 1000	161 per 1000 (124 to 209)	RR 0.78 (0.60 to 1.01)	2490 (11 studies)	⊕⊝⊝⊝ very low^1,3
Quantity of perioperative blood transfused	The mean quantity of perioperative blood transfused in the control groups was 0.08 litres	The mean quantity of perioperative blood transfused in the intervention groups was 0.05 standard deviations higher (0.27 lower to 0.38 higher)		143 (2 studies)	⊕⊝⊝⊝ very low^1,2	SMD 0.05 (‐0.27 to 0.38)
Length of hospital stay		The mean length of hospital stay in the intervention groups was 1.82 lower (3.72 lower to 0.07 higher)		319 (6 studies)	⊕⊝⊝⊝ very low^1,2,4
Number of lymph nodes harvested	The mean number of lymph nodes harvested in the control groups was 27	The mean number of lymph nodes harvested in the intervention groups was 0.63 lower (1.51 lower to 0.25 higher)		472 (9 studies)	⊕⊝⊝⊝ very low^1,4
There were no events in either group for short‐term recurrence (103 participants (3 studies)), proportion requiring blood transfusion (66 participants (2 studies)), proportion with positive resection margin (incomplete cancer resection) (14 participants (1 study)).
None of the trials reported on measures of earlier postoperative recovery such as time to return to normal activity or time to return to work.
The basis for the assumed risk* was the mean control group proportion. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; HR: hazard ratio; RR: risk ratio; SMD: standardised mean difference.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ There was unclear or high risk of bias within the trials (downgraded by two levels). Please see Figure 1 and Figure 2 which show this. ² The confidence intervals were wide (overlaps no effect and clinically significantly effect) and the sample size was small (downgraded by two levels). ³ Visual inspection revealed that studies with large variance were more in the favour of laparoscopic group than the open group, suggesting potential reporting bias (downgraded by one level). ⁴ Significant heterogeneity detected in the studies by the I² values and Chi² test (downgraded by two levels).

Summary of findings 2. Laparoscopic gastrectomy compared to open gastrectomy for gastric cancer (secondary outcomes)

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Comparison 1. Laparoscopic versus open gastrectomy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Short‐term mortality Show forest plot	11	2335	Risk Ratio (M‐H, Fixed, 95% CI)	1.60 [0.50, 5.10]

2 Long‐term mortality (maximal follow‐up) Show forest plot	3	195	Hazard Ratio (Fixed, 95% CI)	0.94 [0.70, 1.25]

3 Proportion with a serious adverse event (< 3 months) Show forest plot	8	432	Risk Ratio (M‐H, Fixed, 95% CI)	0.60 [0.27, 1.34]

4 Short‐term recurrence Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5 Long‐term recurrence (maximal follow‐up) Show forest plot	4		Hazard Ratio (Fixed, 95% CI)	Totals not selected

6 Proportion with an adverse event (< 3 months) Show forest plot	11	2490	Risk Ratio (M‐H, Random, 95% CI)	0.78 [0.60, 1.01]

7 Proportion requiring blood transfusion during or within a week of surgery Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8 Quantity of perioperative blood transfused Show forest plot	2	143	Std. Mean Difference (IV, Fixed, 95% CI)	0.05 [‐0.27, 0.38]

9 Length of hospital stay Show forest plot	8	444	Mean Difference (IV, Random, 95% CI)	‐1.38 [‐2.57, ‐0.19]

10 Proportion with positive resection margins at histopathological examination Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

11 Number of lymph nodes harvested Show forest plot	9	472	Mean Difference (IV, Fixed, 95% CI)	‐0.63 [‐1.51, 0.25]

Comparison 1. Laparoscopic versus open gastrectomy

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Comparison 2. Laparoscopic versus open gastrectomy (subgroup analysis)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Short‐term mortality (stratified by early versus advanced cancer) Show forest plot	7		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 Early gastric cancer	5		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Advanced gastric cancer	2		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Long‐term mortality (maximal follow‐up) (stratified by early versus advanced cancer) Show forest plot	2		Hazard Ratio (Fixed, 95% CI)	Totals not selected

2.1 Early gastric cancer	1		Hazard Ratio (Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 Advanced gastric cancer	1		Hazard Ratio (Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Proportion with a serious adverse event (< 3 months) (stratified by early versus advanced cancer) Show forest plot	5	262	Risk Ratio (M‐H, Fixed, 95% CI)	0.58 [0.21, 1.60]

3.1 Early gastric cancer	4	166	Risk Ratio (M‐H, Fixed, 95% CI)	0.44 [0.14, 1.39]
3.2 Advanced gastric cancer	1	96	Risk Ratio (M‐H, Fixed, 95% CI)	2.88 [0.12, 68.98]
4 Short‐term mortality (stratified by type of gastrectomy) Show forest plot	10		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.1 Subtotal gastrectomy	10	2239	Risk Ratio (M‐H, Fixed, 95% CI)	1.60 [0.50, 5.10]
5 Long‐term mortality (maximal follow‐up) (stratified by type of gastrectomy) Show forest plot	2		Hazard Ratio (Fixed, 95% CI)	Totals not selected

5.1 Subtotal gastrectomy	2		Hazard Ratio (Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Proportion with a serious adverse event (< 3 months) (stratified by type of gastrectomy) Show forest plot	7		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.1 Subtotal gastrectomy	7	336	Risk Ratio (M‐H, Fixed, 95% CI)	0.52 [0.22, 1.22]

Comparison 2. Laparoscopic versus open gastrectomy (subgroup analysis)

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