Twelve studies (n= 951 patients), published between 2000 and 2007, were included in the review, including three RCTs and nine retrospective studies. Seven studies were allocated a quality score of 11 or higher; the range of study quality scores were 8 to 15.
Lymph node clearance: A significantly higher number of lymph nodes were retrieved with the use of open distal gastrectomy (ODG; WMD 4.61 nodes, 95% CI 3.26 to 5.96). In patients who had less than D2 lymphadenectomy performed, there were no significant differences in the number of nodes extracted.
Operative data: There was less operative blood loss for laparoscopy-assisted distal gastrectomy (LADG) compared with (WMD -151.08mL, 95% CI -176.19 to -125.97). The LADG procedures were observed to have a longer operative time (WMD 53.48 minutes, 95% CI 34.49 to 72.48) than the ODG procedures.
Post-operative recovery: There were statistically significant benefits of laparoscopy-assisted distal gastrectomy (LADG) over ODG for a number of postoperative outcomes including: shorter length of hospital stay (WMD -5.72 days, 95% CI -8.16 to -3.28); less time to oral intake (WMD -1.11 days, 95%CI -1.6 to -0.63); less time to flatus (WMD -0.7 days, 95% CI -0.9 to -0.5); less time to walking (WMD -0.82, 95% CI -1.06 to -0.58); and 1.22 fewer days of increased temperature (95% CI -1.7 to -0.75). Post-operative white blood cell and C-reactive protein levels were significantly less in the LADG group at one and three days post-surgery, but there were no differences between groups after one week. The patients in the ODG groups required a mean of 2.05 more days of analgesia (95% CI 1.8 to 2.31); and analgesia use was 1.36 times higher (95% CI 0.28 to 2.44) than the LADG group. There was statistically significant heterogeneity observed across all post-operative recovery outcomes.
Post-operative complications: Overall morbidity was reduced in the LADG group (OR 0.52, 95% CI 0.34 to 0.80), as was intestinal obstruction (OR 0.27, 95% CI 0.09 to 0.84). There were no significant differences between groups in days of post-operative analgesia, post-operative intestinal obstruction, wound infection, anastomic stricture and leakage, and duodenal stump/anastomic leakage. The subgroup analyses showed the same results for all these outcomes.
Subgroup analysis of RCTs (n=103): There were significant benefits found for the use of LADG compared to ODG for operative time, wound size, lymph node clearance, time to walking, use of post-operative analgesia and overall morbidity. There were no differences between treatment groups reported for operative blood loss, time to oral intake, time to flatus, or length of hospital stay.
The results of other subgroup analyses conducted showed the same trends and were of similar magnitude to the meta-analysis of all the studies for each outcome.