Abstract: Objective: The study compared laparoscopy-assisted gastrectomy (LAG) with open gastrectomy (OG) in the management of advanced gastric cancer (AGC). Methods: Literature search was performed in the Medline, Embase, and Cochrane Library databases to identify control studies that compared LAG and OG for AGC. A meta-analysis was conducted to examine the surgical safety and oncologic adequacy, using the random-effect model. Results: Seven eligible studies including 815 patients were analyzed. LAG was associated with less blood loss, less use of analgesics, shorter time of flatus and periods of hospital stay, but longer time of operation. The incidence of most complications was similar between the two groups. However, LAG was associated with a lower rate of pulmonary infection (odds ratio (OR) 0.19; 95% confidence interval (CI) 0.05 to 0.68; P<0.05). No significant differences were noted in terms of the number of harvested lymph nodes (weighted mean difference (WMD) 1.165; 95% CI −2.000 to 4.311; P>0.05), overall mortality (OR 0.65; 95% CI 0.39 to 1.10; P>0.05), cancer-related mortality (OR 0.64; 95% CI 0.32 to 1.25; P>0.05), or recurrence (OR 0.62; 95% CI 0.33 to 1.16; P>0.05). Conclusions: LAG could be performed safely for AGC with adequate lymphadenectomy and has several short-term advantages compared with conventional OG. No differences were found in long-term outcomes. However, these results should be validated in large randomized controlled studies (RCTs) with sufficient follow-up.

[1]Abraham, N.S., Byrne, C.J., Young, J.M., Solomon, M.J., 2010. Meta-analysis of well-designed nonrandomized comparative studies of surgical procedures is as good as randomized controlled trials. J. Clin. Epidemiol., 63(3):238-245.

[2]Cai, J., Wei, D., Gao, C.F., Zhang, C.S., Zhang, H., Zhao, T., 2011. A prospective randomized study comparing open versus laparoscopy-assisted D2 radical gastrectomy in advanced gastric cancer. Dig. Surg., 28(5-6):331-337.

[3]Corley, D.A., Buffler, P.A., 2001. Oesophageal and gastric cardia adenocarcinomas: analysis of regional variation using the cancer incidence in five continents database. Int. J. Epidemiol., 30(6):1415-1425.

[4]Crew, K.D., Neugut, A.I., 2004. Epidemiology of upper gastrointestinal malignancies. Semin. Oncol., 31(4):450-464.

[5]Ding, J., Liao, G.Q., Liu, H.L., Liu, S., Tang, J., 2012. Meta-analysis of laparoscopy-assisted distal gastrectomy with D2 lymph node dissection for gastric cancer. J. Surg. Oncol., 105(3):297-303.

[6]Du, X.H., Li, R., Chen, L., Shen, D., Li, S.Y., Guo, Q., 2009. Laparoscopy-assisted D2 radical distal gastrectomy for advanced gastric cancer: initial experience. Chin. Med. J. (Engl.), 122(12):1404-1407.

[7]Edge, S.B., Compton, C.C., 2010. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann. Surg. Oncol., 17(6):1471-1474.

[8]Frazee, R.C., Roberts, J.W., Okeson, G.C., Symmonds, R.E., Snyder, S.K., Hendricks, J.C., Smith, R.W., 1991. Open versus laparoscopic cholecystectomy. A comparison of postoperative pulmonary function. Ann. Surg., 213(6):651-653, 653-654.

[9]Goetze, T., Paolucci, V., 2006. Does laparoscopy worsen the prognosis for incidental gallbladder cancer? Surg. Endosc., 20(2):286-293.

[10]Gutt, C.N., Riemer, V., Kim, Z.G., Erceg, J., Lorenz, M., 2001. Impact of laparoscopic surgery on experimental hepatic metastases. Br. J. Surg., 88(3):371-375.

[11]Hamabe, A., Omori, T., Tanaka, K., Nishida, T., 2012. Comparison of long-term results between laparoscopy-assisted gastrectomy and open gastrectomy with D2 lymph node dissection for advanced gastric cancer. Surg. Endosc., 26(6):1702-1709.

[12]Hayashi, H., Ochiai, T., Shimada, H., Gunji, Y., 2005. Prospective randomized study of open versus laparoscopy-assisted distal gastrectomy with extraperigastric lymph node dissection for early gastric cancer. Surg. Endosc., 19(9):1172-1176.

[13]Hosono, S., Arimoto, Y., Ohtani, H., Kanamiya, Y., 2006. Meta-analysis of short-term outcomes after laparoscopy-assisted distal gastrectomy. World J. Gastroenterol., 12(47):7676-7683.

[14]Huang, J.L., Wei, H.B., Zheng, Z.H., Wei, B., Chen, T.F., Huang, Y., Guo, W.P., Hu, B., 2010. Laparoscopy-assisted D2 radical distal gastrectomy for advanced gastric cancer. Dig. Surg., 27(4):291-296.

[15]Hur, H., Jeon, H.M., Kim, W., 2008. Laparoscopy-assisted distal gastrectomy with D2 lymphadenectomy for T2b advanced gastric cancers: three years’ experience. J. Surg. Oncol., 98(7):515-519.

[16]Huscher, C.G., Mingoli, A., Sgarzini, G., Sansonetti, A., Di Paola, M., Recher, A., Ponzano, C., 2005. Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: five-year results of a randomized prospective trial. Ann. Surg., 241(2):232-237.

[17]Hwang, S.I., Kim, H.O., Yoo, C.H., Shin, J.H., Son, B.H., 2009. Laparoscopic-assisted distal gastrectomy versus open distal gastrectomy for advanced gastric cancer. Surg. Endosc., 23(6):1252-1258.

[18]Kim, H.H., Hyung, W.J., Cho, G.S., Kim, M.C., Han, S.U., Kim, W., Ryu, S.W., Lee, H.J., Song, K.Y., 2010. Morbidity and mortality of laparoscopic gastrectomy versus open gastrectomy for gastric cancer: an interim report— a phase III multicenter, prospective, randomized Trial (KLASS Trial). Ann. Surg., 251(3):417-420.

[19]Kim, S.H., Milsom, J.W., Gramlich, T.L., Toddy, S.M., Shore, G.I., Okuda, J., Fazio, V.W., 1998. Does laparoscopic vs. conventional surgery increase exfoliated cancer cells in the peritoneal cavity during resection of colorectal cancer? Dis. Colon. Rectum, 41(8):971-978.

[20]Kim, Y.W., Baik, Y.H., Yun, Y.H., Nam, B.H., Kim, D.H., Choi, I.J., Bae, J.M., 2008. Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer: results of a prospective randomized clinical trial. Ann. Surg., 248(5):721-727.

[21]Kim, Z.G., Mehl, C., Lorenz, M., Gutt, C.N., 2002. Impact of laparoscopic CO₂-insufflation on tumor-associated molecules in cultured colorectal cancer cells. Surg. Endosc., 16(8):1182-1186.

[22]Kitano, S., Iso, Y., Moriyama, M., Sugimachi, K., 1994. Laparoscopy-assisted Billroth I gastrectomy. Surg. Laparosc. Endosc., 4(2):146-148.

[23]Kitano, S., Shiraishi, N., Fujii, K., Yasuda, K., Inomata, M., Adachi, Y., 2002. A randomized controlled trial comparing open vs. laparoscopy-assisted distal gastrectomy for the treatment of early gastric cancer: an interim report. Surgery, 131(s1):S306-S311.

[24]Lee, J.H., Han, H.S., Lee, J.H., 2005. A prospective randomized study comparing open vs. laparoscopy-assisted distal gastrectomy in early gastric cancer: early results. Surg. Endosc., 19(2):168-173.

[25]Lee, Y.J., Ha, W.S., Park, S.T., Choi, S.K., Hong, S.C., 2007. Port-site recurrence after laparoscopy-assisted gastrectomy: report of the first case. J. Laparoendosc. Adv. Surg. Tech. A, 17(4):455-457.

[26]Liang, Y., Li, G., Chen, P., Yu, J., Zhang, C., 2011. Laparoscopic versus open gastrectomy for early distal gastric cancer: a meta-analysis. ANZ J. Surg., 81(10):673-680.

[27]MacLehose, R.R., Reeves, B.C., Harvey, I.M., Sheldon, T.A., Russell, I.T., Black, A.M., 2000. A systematic review of comparisons of effect sizes derived from randomised and non-randomised studies. Health Technol. Assess., 4(34):1-154.

[28]McMahon, A.J., Baxter, J.N., Kenny, G., O′Dwyer, P.J., 1993. Ventilatory and blood gas changes during laparoscopic and open cholecystectomy. Br. J. Surg., 80(10):1252-1254.

[29]Miura, S., Kodera, Y., Fujiwara, M., Ito, S., Mochizuki, Y., Yamamura, Y., Hibi, K., Ito, K., Akiyama, S., Nakao, A., 2004. Laparoscopy-assisted distal gastrectomy with systemic lymph node dissection: a critical reappraisal from the viewpoint of lymph node retrieval. J. Am. Coll. Surg., 198(6):933-938.

[30]Mochiki, E., Nakabayashi, T., Kamimura, H., Haga, N., Asao, T., Kuwano, H., 2002. Gastrointestinal recovery and outcome after laparoscopy-assisted versus conventional open distal gastrectomy for early gastric cancer. World J. Surg., 26(9):1145-1149.

[31]Nakajima, T., 2002. Gastric cancer treatment guidelines in Japan. Gastric. Cancer, 5(1):1-5.

[32]Park Do, J., Han, S.U., Hyung, W.J., Kim, M.C., Kim, W., Ryu, S.Y., Ryu, S.W., Song, K.Y., Lee, H.J., Cho, G.S., et al., 2012. Long-term outcomes after laparoscopy-assisted gastrectomy for advanced gastric cancer: a large-scale multicenter retrospective study. Surg. Endosc., 26(6):1548-1553.

[33]Parkin, D.M., Muir, C.S., 1992. Cancer incidence in five continents. Comparability and quality of data. IARC Sci. Publ., (120):45-173.

[34]Petitti, D.B., 1994. Of babies and bathwater. Am. J. Epidemiol., 140(9):779-782.

[35]Powell, J., McConkey, C.C., Gillison, E.W., Spychal, R.T., 2002. Continuing rising trend in oesophageal adenocarcinoma. Int. J. Cancer, 102(4):422-427.

[36]Reza, M.M., Blasco, J.A., Andradas, E., Cantero, R., Mayol, J., 2006. Systematic review of laparoscopic versus open surgery for colorectal cancer. Br. J. Surg., 93(8):921-928.

[37]Shapiro, S., 1994. Meta-analysis/Shmeta-analysis. Am. J. Epidemiol., 140(9):771-778.

[38]Shuang, J., Qi, S., Zheng, J., Zhao, Q., Li, J., Kang, Z., Hua, J., Du, J., 2011. A case-control study of laparoscopy-assisted and open distal gastrectomy for advanced gastric cancer. J. Gastrointest. Surg., 15(1):57-62.

[39]Songun, I., Putter, H., Kranenbarg, E.M., Sasako, M., van de Velde, C.J., 2010. Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial. Lancet Oncol., 11(5):439-449.

[40]Strong, V.E., Devaud, N., Allen, P.J., Gonen, M., Brennan, M.F., Coit, D., 2009. Laparoscopic versus open subtotal gastrectomy for adenocarcinoma: a case-control study. Ann. Surg. Oncol., 16(6):1507-1513.

[41]Strong, V.E., Song, K.Y., Park, C.H., Jacks, L.M., Gonen, M., Shah, M., Coit, D.G., Brennan, M.F., 2010. Comparison of gastric cancer survival following R0 resection in the United States and Korea using an internationally validated nomogram. Ann. Surg., 251(4):640-646.

[42]Tokunaga, M., Hiki, N., Fukunaga, T., Miki, A., Nunobe, S., Ohyama, S., Seto, Y., Yamaguchi, T., 2009. Quality control and educational value of laparoscopy-assisted gastrectomy in a high-volume center. Surg. Endosc., 23(2):289-295.

[43]Vinuela, E.F., Gonen, M., Brennan, M.F., Coit, D.G., Strong, V.E., 2012. Laparoscopic versus open distal gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials and high-quality nonrandomized studies. Ann. Surg., 255(3):446-456.