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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

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

MA Memon, S Khan, RM Yunus, R Barr, and B Memon.

Review published: 2008.

Link to full article: [Journal publisher]

CRD summary

The review concluded that clear-cut benefits of laparoscopic-assisted over open distal gastrectomy for patients with gastric cancer were rather limited; its widespread adaptation could not be recommended. Given the possibility of the omission of relevant trials and the lack of investigation into causes of variation between trials, a degree of is required caution when interpreting the authors' conclusions.

Authors' objectives

To compare the relative merits of laparoscopic-assisted gastrectomy with open distal gastrectomy for gastric cancer.


PubMed, EMBASE, Science Citation Index, and Current Contents were searched between January 1990 and June 2007 for studies published in full, in English language, and in peer-reviewed journals; search terms were reported. Unpublished studies and conference abstracts were excluded. Reference lists of relevant studies were scanned.

Study selection

Randomised trials that compared laparoscopic-assisted gastrectomy with open distal gastrectomy in patients with gastric cancer were eligible for inclusion. Tumour recurrence and mortality were among the eight listed outcomes of interest.

Most included trials were published in 2005, with two conducted in Japan, one in Korea, and one in Italy. Most participants were in their late 50s or early 60s and had comorbidities.

It appeared that three reviewers independently selected studies for inclusion.

Assessment of study quality

Two reviewers evaluated trial quality using the Jadad scale (assessing randomisation, blinding and withdrawals/drop-outs). Trials were awarded a score out of a maximum of 5 points.

Data extraction

Three reviewers independently extracted data in order to calculate odd ratios (OR) and mean differences, with 95% confidence intervals (CI).

Methods of synthesis

Meta-analyses were performed to calculate pooled odds ratios or weighted mean differences (WMD) using a random-effects model. Statistical heterogeneity was assessed using the χ2 test.

A sensitivity analysis was performed to assess the effect of trial quality where poor quality trials (that scored 1 on the Jadad scale) were removed.

Funnel plots were used to assess for publication bias; their limited use with a small number of trials was highlighted.

Results of the review

Four trials were included in the review (n=162 patients, range 28 to 59). The quality of trials (overall) was described as being poor (mean score 2.7 out of 5).

Laparoscopic surgery was associated with significantly less intraoperative blood loss than open surgery (WMD -104.3mL, 95%CI -189.0 to -19.5; four trials), but with a longer operating time (WMD 83.1 minutes, 95% CI 40.5 to 125.6; four trials). There was a significant reduction in lymph nodes harvesting (WMD -4.3, 95% CI -6.7 to -2.0; four trials). The blood loss and operating time analyses were found to have statistically significant tests for heterogeneity.

There were no significant differences between types of operation for the following outcomes: time to commencement of oral intake, length of hospital stay, rate of complications, mortality rate, and tumour recurrence (all included four trials). The time to commencement of oral intake and length of hospital stay outcomes were found to have statistically significant tests for heterogeneity.

Authors' conclusions

The clear-cut benefits of laparoscopic-assisted gastrectomy over open distal gastrectomy were rather limited, and its widespread adaptation could not be recommended.

CRD commentary

The review addressed a clear question, supported by suitable inclusion criteria. Although several relevant databases were searched, the restriction to only including trials published in English meant that relevant data may have been missed, and the possibility of language or publication bias affecting the review results could not be ruled out. It appeared that suitable methods were used throughout the review to reduce the risk of reviewer error and bias occurring.

A basic trial quality assessment was performed, but was used little in interpreting the review results. Meta-analyses were conducted, but many of the analyses were associated with very significant heterogeneity (so the pooled values should be interpreted with caution). No investigations were made into the possible causes of heterogeneity, and very few details of the individual trials were provided (to allow independent assessment).

Although the authors' conclusions broadly appeared to reflect the evidence presented, a degree of caution in their interpretation is warranted due to the possibility of relevant studies being omitted, and the lack of investigation into causes of heterogeneity.

Implications of the review for practice and research

Practice: The authors stated that the widespread adaptation of laparoscopic-assisted distal gastrectomy cannot be recommended.

Research: The authors stated that multi-centre randomised trials are required with large enough sample sizes and long enough follow-up periods.


Not stated.

Bibliographic details

Memon MA, Khan S, Yunus RM, Barr R, Memon B. Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma. Surgical Endoscopy 2008; 22(8): 1781-1789. [PubMed: 18437472]

Indexing Status

Subject indexing assigned by NLM


Blood Loss, Surgical; Carcinoma /surgery; Eating; Gastrectomy /adverse effects /methods; Humans; Incidence; Intraoperative Complications /epidemiology; Laparoscopy; Length of Stay; Lymph Node Excision /statistics & numerical data; Postoperative Complications /epidemiology; Postoperative Period; Randomized Controlled Trials as Topic; Stomach Neoplasms /surgery; Time Factors



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 18437472