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Comparison of short-term surgical outcomes and post-operative recovery between single-incision and multi-port laparoscopic distal gastrectomy for gastric cancer
Lin Lin1, Qingwen Xu2, Feipeng Xu2, Caijin Zhou2, Xianjin Huang2, Rihong Chen2, Haiping Jiang3
1 Department of General Surgery, The First Affiliated Hospital, Jinan University, Guangzhou; Department of Gastrointestinal Surgery, The Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
2 Department of Gastrointestinal Surgery, The Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
3 Department of General Surgery, The First Affiliated Hospital, Jinan University, Guangzhou, China
|Date of Submission||05-Jul-2021|
|Date of Acceptance||05-Jan-2022|
|Date of Web Publication||01-Mar-2022|
Department of General Surgery, The First Affiliated Hospital, Jinan University, No. 613, Huangpu Dadao West, Guangdong 510000
Source of Support: None, Conflict of Interest: None
Background: To summarise data from previous reports and perform a meta-analysis to compare the short-term surgical outcomes and post-operative recovery between single-incision and multi-port laparoscopic distal gastrectomy (MLDG) for gastric cancer.
Methods: A systematic literature search was performed using PubMed and Embase databases and relevant data were extracted. Short-term surgical outcomes and post-operative recovery of single-incision laparoscopic distal gastrectomy (SLDG) and MLDG for gastric cancer were compared using a fixed or random-effect model.
Results: In total, we identified five relevant studies involving 983 participants for this systematic review and meta-analysis, and 45.8% (450/983) of patients underwent SLDG. The results demonstrated that mean operation time (weighted mean difference [WMD]:-3.22, 95% confidence interval [CI]: 14.64,8.19, P = 0.580; I2 = 75.6%), intra-operative blood loss (WMD:-19.77, 95% CI: 40.20,0.65, P = 0.058; I2 = 85.0%) and lymph node yield (WMD:-0.71, 95% CI: 1.47, 0.05, P = 0.068; I2 = 0%) of SLDG were comparable to those of MLDG for gastric cancer. In addition, SLDG had a similar incidence of post-operative complications compared with MLDG (odds ratio: 0.82, 95% CI: 0.55-1.22, P = 0.326; I2 = 0%). There was no significant difference between the two surgical procedures for the conversion to open surgery (OR: 0.32, 95%CI: 0.03-3.15, P = 0.331; I2 = 0%), the length of hospital stay (WMD:-0.05, 95% CI: 0.65, 0.55, P = 0.876; I2 = 44.1%), the time to first flatus (WMD:-0.24, 95% CI: 0.58, 0.10, P = 0.169; I2 = 85.3%) and the time to oral intake (WMD:-0.05, 95% CI: 0.20, 0.10, P = 0.500; I2 = 0%).
Conclusion: Single-incision laparoscopic gastrectomy may be technically feasible and safe for gastric cancer. However, it did not show a more obvious advantage over MLDG.
Keywords: Gastric cancer, laparoscopic gastrectomy, laparoscopic surgery, short-term outcomes, single-incision
|How to cite this URL:|
Lin L, Xu Q, Xu F, Zhou C, Huang X, Chen R, Jiang H. Comparison of short-term surgical outcomes and post-operative recovery between single-incision and multi-port laparoscopic distal gastrectomy for gastric cancer. J Min Access Surg [Epub ahead of print] [cited 2022 May 28]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=338929
| ¤ Introduction|| |
Despite an overall declining trend in incidence over the past decades, gastric cancer remains a common cause of cancer-related deaths worldwide according to Global Cancer Statistics 2018. R0 surgical resection with lymphadenectomy is the most effective treatment option for resectable gastric cancer patients. To date, laparoscopic gastrectomy has been widely accepted as an alternative surgical procedure for early gastric cancer, with reduced surgical trauma and pain, faster post-operative recovery in comparison to open gastrectomy.,, It has been suggested that long-term oncologic outcome of laparoscopic gastrectomy was comparable to that of open gastrectomy for early gastric cancer., Recently, the indication for laparoscopic surgery was further expanded to more advanced gastric cancer, and an increasing evidence demonstrated that it is safe and oncologically feasible.,
With the advancement in surgical techniques and instruments, current laparoscopic surgery has shifted towards further reducing invasiveness and improving quality of life. Compared with traditional multi-port laparoscopic gastrectomy, reduced-port laparoscopic surgery is expected to further lower surgical trauma and pain, and improve cosmetic outcomes. It has been shown that reduced-port laparoscopic gastrectomy has a similar short-term surgical outcome compared with conventional laparoscopic gastrectomy for gastric cancer., As experience with laparoscopic surgery accumulates, single-incision laparoscopic gastrectomy has been reported by several institutions.,, This novel surgical approach was performed by surgeons via only one transumbilical incision to maximise the superiority of laparoscopic surgery. To date, several studies have compared short-term surgical outcomes and post-operative recovery of single-incision laparoscopic gastrectomy with multi-port laparoscopic gastrectomy.,,,,,, However, the small sample size of these studies limited the statistical power of the results. The current evidence of individual study was insufficient to determine the potential benefits of single-incision relative to multi-port laparoscopic gastrectomy for gastric cancer. In the present study, we summarised data from previous reports on this topic and performed a meta-analysis to compare the short-term surgical outcomes and post-operative recovery between the two surgical procedures.
| ¤ Methods|| |
Literature search strategy
Based on the recent guideline on optimal literature search methods for surgical reviews, a comprehensive literature search was conducted up to 01 April 2021 using Medline (via PubMed), Web of Science, Embase and Cochrane Library databases. The search term and keywords were used: 'gastric cancer,' 'single-incision' or 'single-incision,' 'laparoscopic' or 'laparoscopy,' and 'gastrectomy'. Additional records were identified by a manual search of the reference lists of the included articles. There was no language or publication date restriction for the search of relevant literature. Searched titles and abstracts were initially screened by two investigators for evaluating the topic's relevance. Studies deemed potentially relevant were further assessed by full text for inclusion. This study was designed and completed following the preferred reporting items for systematic reviews and meta-analysis checklist statement.
Eligible studies reported on a comparison of short-term surgical outcomes and/or post-operative recovery between single-incision and multi-port laparoscopic distal gastrectomy (MLDG) for gastric cancer. Patients with a tumour located in the upper one-third of the stomach or who underwent laparoscopic total gastrectomy should be excluded from the study. The studies were excluded if they failed to report at least one of the prespecified outcomes or they were from review articles, case reports, conference abstracts or were non-comparative studies. In case of studies with overlapping data reported by the same research group or institution, the most recent or the most informative or highest quality report was included. Searched titles, abstracts and full-text screening were conducted independently by two investigators to identify studies fulfilling the inclusion criteria.
Data extraction and quality assessment
After reviewing the abstracts and full text, data extraction was independently performed by two investigators using an electronic form. For each included study, the primary author's name, publication year, country of study populations, study design, study period, sample size, patients' baseline characteristics and TNM stage were collected. The primary outcome of this meta-analysis included surgical outcomes (operation time, intra-operative blood loss and lymph node yield), post-operative complications and post-operative recovery (time to first flatus, time to oral intake and the length of hospital stay). All predefined outcomes were collected from the main text, tables or supplementary materials, and relevant data were extracted for further analysis.
The Cochrane risk of bias tool (ROBINS-I) was used to evaluate the methodological quality of included studies. The risk of bias was recorded as 'Low risk', 'Moderate risk', 'Serious risk' or 'Critical risk' according to the relevant items. The overall risk of bias of each study was then determined through the combination of the assessment domains. The quality assessment of included studies was performed independently by two investigators.
If continuous data were reported as median and range (or interquartile range) in the original literature, they should be converted to mean and standard deviation according to the method by Hozo et al. and the instructions from Cochrane Handbook. The pooled analysis was performed by calculating the weighted mean difference (WMD) and 95% confidence intervals (CIs). For categorical data, the pooled analysis was performed by calculating the odds ratio (OR) and 95% CIs.
The heterogeneity among studies was quantified using the Cochran Q-test and I2 statistic. We considered I2 >50% and/or P < 0.01 represent a considerable heterogeneity. If significant statistical heterogeneity was observed, a random effect model should be adopted; otherwise, a fixed-effect model should be used. A funnel plot was generated to visually evaluate the potential publication bias. All statistical analyses for comparing short-term surgical outcomes and post-operative recovery between single-incision and MLDG were performed using the Stata 14.0 software (Stata, TX, USA). The P value cutoff for statistical significance was set at 0.05.
| ¤ Results|| |
Search results and study characteristics
The flow diagram of the study selection is presented in [Figure 1]. According to the predefined search strategy, the initial search via electronic databases yielded 106 potentially relevant studies. We excluded 90 irrelevant studies after scanning the titles and abstracts. Subsequently, the full text of the remaining 16 reports was obtained for further assessment, with eight more studies being excluded according to the inclusion and exclusion criteria. Among these studies, 4 reports did not provide available data or outcomes for pooled analysis, 4 were review articles and 1 study included an overlapping patient population. Ultimately, we identified 7 relevant studies for the final qualitative or quantitative analysis.,,,,,,
The characteristics of the included studies and patients are summarised in [Table 1]. All included studies were published between 2014 and 2020. Three studies were from South Korea, two studies were from China, and two studies were from Japan. The total number of study participants was 983, with a range of sample sizes from 60 to 297. In total, 45.8% (450/983) of patients underwent single-incision laparoscopic distal gastrectomy (SLDG) and 54.2% (533/983) of patients underwent MLDG for gastric cancer. According to the Cochrane risk of bias tool (ROBINS-I), only one study had a high risk of bias and other studies had a moderate risk of bias, suggesting that the methodological quality of included studies was acceptable.
Comparison of short-term outcomes and post-operative recovery between single-incision and multi-port laparoscopic distal gastrectomy for gastric cancer
Operation time of single-incision and MLDG for gastric cancer was reported by all included studies. The results of this meta-analysis indicated that the mean operation time of SLDG was not significantly different from that of MLDG, but a significant heterogeneity was observed among studies (WMD: 3.22, 95% CI: 14.64, 8.19, P = 0.580; I2 = 75.6%) [Figure 2].
|Figure 2: Forest plots comparing the operation time between single-port and multi-port laparoscopic distal gastrectomy for gastric cancer|
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Seven studies were included in this meta-analysis to compare the amount of intraoperative blood loss between single-incision and MLDG. The pooled results showed no significant difference between the two surgical procedures for intraoperative blood loss, with a significant heterogeneity (WMD: 19.77, 95% CI: 40.20, 0.65, P = 0.058; I2 = 85.0%) [Figure 3].
|Figure 3: Forest plots comparing the amount of intra-operative blood loss between single-port and multi-port laparoscopic distal gastrectomy for gastric cancer|
Click here to view
In addition, the pooled data demonstrated that the number of lymph node harvest for SLDG was comparable to that for MLDG, without evidence of significant heterogeneity (WMD: 0.71, 95% CI: 1.47, 0.05, P = 0.068; I2 = 0%) [Figure 4].
|Figure 4: Forest plots comparing lymph node yield between single-port and multi-port laparoscopic distal gastrectomy for gastric cancer|
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All included reports provided available data on the presence of post-operative complications, and the results revealed that SLDG for gastric cancer had a similar incidence of post-operative complications compared with MLDG (OR: 0.82, 95% CI: 0.55–1.22, P = 0.326; I2 = 0%) [Figure 5]. Similar finding was also observed in Clavien-Dindo grade ≥II complications (OR: 1.04, 95% CI: 0.62–1.76, P = 0.878; I2 = 0%) [Table 2].
|Figure 5: Forest plots comparing post-operative complications between single-port and multi-port laparoscopic distal gastrectomy for gastric cancer|
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|Table 2: Comparison of post-operative outcomes between single-port and multi-port laparoscopic distal gastrectomy|
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Compared to MLDG, SLDG failed to show an obvious advantage in terms of post-operative recovery. There was no significant difference between the two surgical procedures for the length of hospital stay (WMD: 0.05, 95% CI: 0.65, 0.55, P = 0.876; I2 = 44.1%), time to first flatus (WMD: 0.24, 95% CI: 0.58, 0.10, P = 0.169; I2 = 85.3%) and time to oral intake (WMD: 0.05, 95% CI: 0.20, 0.10, P = 0.500; I2 = 0%). In addition, no difference between single-incision and MLDG was observed for the conversion to open surgery (OR: 0.32, 95% CI: 0.03–3.15, P = 0.331; I2 = 0%) [Table 2].
The funnel plot for the comparison of post-operative complications was generated to detect publication bias. Based on the visual assessment, the asymmetric distribution of main studies was not observed, indicating that the results of this meta-analysis were unlikely to be explained by publication bias [Figure 6].
| ¤ Discussion|| |
In 2011, Omori et al. first reported the therapeutic effect of single-incision laparoscopic gastrectomy for gastric cancer. Since then, some studies further showed the superiority of this surgical approach with regard to post-operative recovery and cosmetic outcomes., However, previous reports were based on a single institution, small sample size and retrospective design. There was no sufficient evidence on the feasibility and safety of single-incision laparoscopic gastrectomy for gastric cancer. In this systematic review and meta-analysis, we compared the short-term surgical outcomes and post-operative recovery between single-incision and MLDG for gastric cancer. Our results demonstrated that SLDG provided a comparable operation time, intraoperative blood loss and lymph node yield compared with MLDG. In addition, there was no significant difference between the two surgical procedures in terms of post-operative complications and post-operative recovery.
To date, single-incision laparoscopic surgery has been applied to the treatment of gallbladder stones, endometrial cancer and colorectal cancer.,,, Unlike benign diseases and other malignancies, lymph node dissection for gastric cancer was a complicated and challenging surgical task for laparoscopic surgeons. This surgical procedure usually needs a wider operation field, thus it seems to be more technically difficult in single-incision manipulation despite lesser invasive. However, the technical problem could be overcome by a flexible laparoscope and a transverse umbilical incision instead of a vertical incision. In this meta-analysis, mean operation time, intra-operative blood loss and lymph node yield of SLDG were comparable to those of MLDG for gastric cancer.
Under the current concept of minimally invasive treatment, single-incision laparoscopic surgery seems to meet the increasing demand for quality of life and cosmetic outcomes. Although some studies showed that the reduction in the number of handle ports brought lesser post-operative pain,, similar findings were not reported by other studies., In addition to the number of handle ports, wound pain was associated with various factors such as the length of the incision and patient's characteristics. On the other hand, the appraisal of post-operative pain tended to be subjective. Based on current evidence, it is difficult to evaluate the advantage of single-incision laparoscopic surgery for reducing pain. Two studies consistently reported that single-incision laparoscopic gastrectomy had a shorter abdominal incision than multi-port laparoscopic surgery for gastric cancer., More importantly, a transverse umbilical incision only formed a faint scar at several months after surgery due to a well-matched direction of the skin folds and surgical scar. Therefore, single-incision laparoscopic surgery may provide more excellent cosmetic outcomes for gastric cancer patients. Another advantage of single-incision laparoscopic surgery was reduced surgical trauma, which may accelerate post-operative recovery. Omori et al. reported that the count of white blood cells after surgery was not different between the two surgical procedures, but the level of serum C-reactive protein was significantly lower in single-incision laparoscopic gastrectomy than in multi-port laparoscopic gastrectomy throughout the post-operative course, suggesting a lesser inflammatory response and surgical trauma. However, no significant difference between the two surgical procedures for post-operative complications and post-operative recovery was observed in this meta-analysis. One potential explanation for these findings was that all surgical procedures were performed by experienced surgeons. Therefore, the advantage of single-incision laparoscopic surgery for post-operative recovery was not fully apparent.
In addition to the feasibility of single-incision laparoscopic gastrectomy, the most critical aspect of surgical treatment of gastric cancer was its oncological safety. To date, the data on the long-term oncologic outcome of single-incision laparoscopic gastrectomy for gastric cancer has been still lacking. In five included studies, the only report of Omori et al. showed overall survival (OS) and recurrence-free survival (RFS) outcome of single-incision laparoscopic gastrectomy for gastric cancer. The results indicated that the 5-year OS (93.7% vs. 87.6%, P = 0.689) and 5-year RFS (90.0% vs. 87.6%, P = 0.958) of single-incision laparoscopic gastrectomy were not different from those of multi-port laparoscopic gastrectomy for clinical stage I-III gastric cancer. These findings supported the oncological safety of single-incision laparoscopic gastrectomy for gastric cancer. However, high-level randomised controlled trials are still required to evaluate the long-term oncological outcomes of single-incision laparoscopic gastrectomy for gastric cancer.
Several limitations of this analysis require to be considered. First, the level of current evidence is not high enough. All results and conclusions were based on retrospective investigations with a small sample size, and selection bias might have existed. Second, the laparoscopic surgical technique and experience of the surgeons could have affected the analytic results. In most of the included studies, laparoscopic gastrectomy was performed by experienced surgeons. Stable surgical techniques and rich experience have been established, which might have a little impact on the short-term surgical outcomes of laparoscopic gastrectomy for gastric cancer.
| ¤ Conclusion|| |
The results of this systematic review and meta-analysis demonstrated that the short-term surgical outcomes and post-operative recovery of SLDG were comparable to those of multi-port laparoscopic gastrectomy for gastric cancer. This surgical approach may be technically feasible and safe for minimally invasive treatment of gastric cancer. However, randomized controlled trials with larger sample sizes are still necessary to further confirm its short-term surgical outcomes and long-term oncological outcome.
Financial support and sponsorship
This work was supported by grants obtained from the Clinical Research Project of Affiliated Hospital of Guangdong Medical University (No. LCYJ2019C004). The funder did not make any substantive contributions to the article.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]