[Safety and efficacy of hand-assisted laparoscopic versus open distal gastrectomy for gastric cancer: A systematic review and meta-analysis].
OBJECTIVE
To systematically assess the safety and efficacy of hand-assisted laparoscopic distal gastrectomy (HALG) versus open distal gastrectomy (ODG) for gastric cancer.


METHODS
Chinese or English literature regarding comparison of HALG and ODG were collected by searching in databases (such as PubMed, Cochrane Library, CNKI, Wanfang database) between January 1996 and September 2016. The data of operative time, incision length, blood loss, number of harvested lymph nodes, time to flatus, hospital stay, postoperative complication morbidity and long-term outcomes were compared between the two procedures. Then funnel plot was used to evaluate publication bias and sensitivity analysis was used to evaluate the stability of the results. All these data analyses were performed using the Meta for or Meta package of R version 3.3.1.


RESULTS
A total of 7 studies with 835 patients (323 cases in HALG group and 512 cases in ODG group) were included. Compared with ODG, HALG had a longer operative time (WMD=28.93 minutes, 95%CI=9.59 to 48.28, Z=2.93, P=0.000), a shorter incision length (WMD=-10.31 cm, 95%CI=-14.01 to -6.62, Z=-5.47, P=0.000), less blood loss (WMD=-140.08 ml, 95%CI=-215.07 to -65.09, Z=-3.66, P=0.000), faster gastrointestinal recovery (WMD=-1.23 days, 95%CI=-1.89 to -0.56, Z=-3.62, P=0.000), shorter postoperative hospital stay (WMD=-3.24 days, 95%CI=-5.47 to -1.02, Z=-2.85, P=0.000). In subgroup analysis, 3 studies published before 2013 vs. 4 studies published afterwards, the number of harvested lymph nodes (WMD=-0.78, 95%CI=-2.05 to 0.50, Z=-1.19, P=0.235) and postoperative complication morbidity (RR=1.02, 95%CI=0.43 to 2.44, Z=0.05, P=0.961) did not differ significantly between two groups. Compared with ODG, the RR(95%CI) of ileus of HALG was 0.43 (0.07 to 2.82), but the difference was not statistically significant (P=0.383). One study reported the 5-year overall survival rates of HALG and ODG were 81.0% vs 67.5%, and the tumor recurrence rates were 7.1% vs 22%, respectively, but the differences were not statistically significant(all P>0.05). Sensitivity analysis showed that the above results were stable. The funnel plots of the lymph nodes and postoperative complication morbidity did not present significant publication bias.


CONCLUSIONS
HALG has the advantages of minimal invasiveness such as shorter incision length and quicker recovery. Furthermore, the short-term efficacy of HALG is similar to conventional open surgery. However, the long-term efficacy is lack of support from multicenter long-term follow-up results.
Center of General Surgery, the People's Liberation Army General Hospital of Chengdu Command, Chengdu 610083, China.
Guibing
G
Chen
Medical Imaging Department, the Jinsha Hospital of Chengdu, Chengdu 610091, China.
Xiaoqian
X
Xu
Center of General Surgery, the People's Liberation Army General Hospital of Chengdu Command, Chengdu 610083, China.
Jiaqing
J
Gong
Center of General Surgery, the People's Liberation Army General Hospital of Chengdu Command, Chengdu 610083, China.
Guohu
G
Zhang
Center of General Surgery, the People's Liberation Army General Hospital of Chengdu Command, Chengdu 610083, China. yongkuancao@163.com.
Yongkuan
Y
Cao
Center of General Surgery, the People's Liberation Army General Hospital of Chengdu Command, Chengdu 610083, China.
Lin
L
Zhang
D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D057186:Comparative Effectiveness Research; D005743:Gastrectomy / Q000379:methods*; D058733:Hand-Assisted Laparoscopy / Q000009:adverse effects*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008197:Lymph Node Excision / Q000706:statistics & numerical data; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology; D061646:Operative Time; D011183:Postoperative Complications / Q000453:epidemiology; D011184:Postoperative Period; D020127:Recovery of Function; D013274:Stomach Neoplasms / Q000401:mortality / Q000601:surgery*; D015996:Survival Rate; D013995:Time; D016896:Treatment Outcome