Intracorporeal versus extracorporeal anastomosis after laparoscopic gastrectomy for gastric cancer. A systematic review with meta-analysis

Aim: To perform a systematic review and meta-analyses of studies comparing the totally laparoscopic procedures with intracorporeal anastomosis (IA) to laparoscopic-assisted surgery with extracorporeal anastomosis (EA) in gastric resections. Methods: We performed a systematic search in the electronic databases. Outcomes analysed were: intraoperative (operative time and intraoperative blood loss), oncologic (harvested nodes, distance of the tumour from proximal and distal margin), postoperative complications (gastric stasis, intraluminal and extraluminal bleeding, leakage and wound infection) recovery (time to first flatus, time to first oral intake and hospital stay). We performed meta-regression analyses after implementing a regression model with the analysed outcomes as dependent variables (y) and the demographic and pathologic covariates as independent variables (x). Results: A total of 26 studies (20 on distal gastrectomy and 6 on total gastrectomy) were included in the final analysis. Regarding distal gastrectomy, there was no statistical difference between the two groups in the above-mentioned outcomes, except for intraoperative blood loss (less in IA group, P = 0.003), number of harvested nodes (better in the IA group, P = 0.022) and length of hospital stay (shorter in the IA group, P = 0.037). Regarding total gastrectomy, there was no statistical difference for all outcomes, except for the distal margin (further in the EA group, P = 0.040). Meta-regression analysis showed that a lot of variables influenced results in distal gastric resections, but not in total gastric resections. Conclusion: We can state laparoscopic gastric resections with IA are safe and feasible when performed by expert surgeons. However, new well-designed studies comparing the two techniques are needed to confirm the benefits of laparoscopic IA.