Comparative study between total and subtotal gastrectomy for ...

Subtotal or total gastrectomy for gastric cancer: impact of the surgical procedure on morbidity and prognosis—analysis of a 10-year experi- ence. Langenbecks ... Inicio CirugíaEspañola(EnglishEdition) Comparativestudybetweentotalandsubtotalgastrectomyfordistalgastriccanc... ISSN:2173-5077 CirugíaEspañola,anofficialbodyoftheAsociaciónEspañoladeCirujanos(SpanishAssociationofSurgeons),willconsideroriginalarticles,reviews,editorials,specialarticles,scientificletters,letterstotheeditor,andmedical imagesforpublication;allofthesewillbesubmittedtoananonymousexternalpeerreviewprocess.ThereisalsothepossibilityofacceptingbookreviewsofrecentpublicationsrelatedtoGeneralandDigestiveSurgery. ThearticlespublishedinCirugíaEspañolacanbefoundsummarisedandindexedinScienceCitationIndexExpanded,JournalCitationReports,IndexMedicus/MEDLINE,Scopus,EMCare,Scirus,IBECSandIME. 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Seemore SNIP2021 0.61 Viewmoremetrics Hide JournalInformation Previousarticle | Nextarticle Vol.98.Issue10.Pages582-590(December2020) LeeesteartículoenEspañol Exportreference Share Share Print DownloadPDF Morearticleoptions ePub Statistics Outline AbstractKeywordsResumenPalabrasclaveIntroduction AbstractKeywordsResumenPalabrasclaveIntroductionMethodsSearchstrategyInclusioncriteriaandstudyobjectivesDatacollectionStatisticalanalysisResultsArticlesearchandselectionResultsofthemeta-analysisDiscussionBackgroundforthemeta-analysisCharacteristicsofthestudiesincludedPostoperativecomplicationsAnastomoticfistulaPostoperativemortalityResectedlymphnodesLong-termsurvivalLimitationsofthemeta-analysisConclusionsFundingConflictofinterestBibliography Visits 410 Vol.98.Issue10.Pages582-590(December2020) Reviewarticle DOI:10.1016/j.cireng.2020.11.013 Fulltextaccess Comparativestudybetweentotalandsubtotalgastrectomyfordistalgastriccancer:Meta-analysisofprospectiveandretrospectivestudies Estudiocomparativoentrelagastrectomíatotalysubtotalenelcáncerdistaldeestómago:metaanálisisdeestudiosprospectivosyretrospectivos Visits ... DownloadPDF HipólitoDuránGiménez-Ricoa,b, Correspondingauthor [email protected]. ,LucíaDiéguezAguirrea,LucíaRíosPéreza,PabloCardinal-Fernándezc,RiccardoCarusoa,b,ValentinaFerria,b,YolandaQuijanoCollazoa,b,d,EmilioVicenteLópeza,b,daServiciodeCirugíaGeneral,DepartamentodeCienciasMédicasClínicas(SeccióndeCirugía),HospitalUniversitarioHMSanchinarro,UniversidadSanPabloCEU,Madrid,SpainbFundaciónparaelDesarrolloeInvestigacióndeCirugíaOncológica,Madrid,SpaincDepartamentodeCuidadosIntensivos,HospitalUniversitarioHMSanchinarro,Madrid,SpaindCátedraInternacionaldeInvestigaciónenCirugíaGeneralyDigestiva,UniversidadCatólicadeMurcia,Murcia,Spain Thisitemhasreceived ... Visits (Dailydataupdate) Articleinformation Abstract FullText Bibliography DownloadPDF Statistics Figures(6)ShowmoreShowlessTables(2)Table1.Characteristicsofthearticlesincludedinthemeta-analysis.Table2.SummaryofthestatisticsobtainedfromthecomparisonbetweenDGandTG.ShowmoreShowless AbstractThereisnoclearagreementonthetypeofgastrectomytobeused(eithertotal[TG]ordistal[DG])inmiddleordistalgastriccancer,especiallywhenitisundifferentiatedorLaurendiffusetype.Inthismeta-analysis,weintendtodefinewhichofthetwotechniquesshouldberecommended,basedonsurvival,morbidityandmortalityrates.Prospectiveandretrospectivestudiescomparingbothtechniqueshavebeenincludedforatotalof6303patients(3,641DGand2,662 TG).DGwassignificantlyassociatedwithfewercomplications,feweranastomoticfistulae,andlessperioperativemortality.ThenumberoflymphnodesinDGwassignificantlylower,butalwaysabove15.Finally,eventhe5-yearsurvivalofDGwasalsohigher.Therefore,distalgastrectomy,aslongasasafetymarginisobtainedandregardlessofthehistologicaltype,shouldbeperformedinsurgeryfordistalstomachcancer.Keywords:GastriccancerGastrectomyTotalgastrectomySubtotalgastrectomyResumenEltipodegastrectomía,total(GT)odistal(GD),enelcáncergástricomedioodistalnoestáclaramenteconsensuada,sobretodocuandoesindiferenciadoodifusodeLauren.Pretendemosenestemetaanálisisdefinirentérminosdesupervivenciaymorbimortalidadcuáldelasdostécnicasdebieraserrecomendada.Sehanincluidotrabajosprospectivosyretrospectivosquecomparenambastécnicashastauntotalde6303pacientes(3.641GDy2.662 GT).LaGDseasociódeformasignificativaconmenoscomplicaciones,menosfístulasanastomóticasymenosmortalidadperoperatoria.ElnúmerodegangliosenlaGDfuesignificativamentemenor,perosiempreporencimade15.Finalmente,lasupervivenciaacincoañosdelaGDfuetambiénsuperior.Portanto,lagastrectomíadistal,siemprequeseobtengaunmargendeseguridadeindependientementedeltipohistológico,debeserrealizadaenlacirugíadecáncerdistaldeestómago.Palabrasclave:CáncergástricoGastrectomíaGastrectomíasubtotalGastrectomíatotal FullText IntroductionGastriccanceristhefifthmostcommoncancer.In2018,morethanonemillioncaseswerediagnosedworldwide.Itsprognosisisuncertain—infact,outofthealmost10millioncancer-relateddeathsintheworldthatyear,782,685(8.2%)weresecondarytostomachcancer.1,2Surgeryisanessentialpillarinthemultidisciplinarytreatmentofthisdisease.AlthoughmorethanacenturyhaspassedsinceBillrothandSchlatterperformed,respectively,thefirstsubtotalgastrectomy(subtotaldistalgastrectomy[DG])andthefirsttotalgastrectomy(TG)instomachcancer,3,4thereisstillnowidespreadagreementaboutwhichoptionisthebestsurgicaltreatmentfordistalandmiddle-thirdstomachcancer.Thebestsurgeryforgastricadenocarcinomashouldcontemplatecompletelocoregionalexcisionofthediseasewithnegativeresectionmargins,butwithoutforgettingkeyissuessuchasthemorbidityandmortalityofthesurgeryandpostoperativepatientqualityoflife.Theextensionoflymphnodedissectionhasbeenthesubjectofdebateinthepast.Currently,mostsurgeonsfavoraD2,lymphadenectomybecauseitguaranteesalowerrateoflocalrecurrence,bettersurvivalresults,D1,isreservedforelderlypatientsorthosewithcomorbiditiesduetothehighermorbidity,mortalityofD2.However,whenitcomestoacancerlocatedinthemiddleordistalthirdsofthestomach,thereisnotmuchconsensusregardingtheextentofresectionofthestomachitself.Someauthorsarguethattheresectionmustbe,aTG,regardlessofthelocationofthetumor,especiallywhendealingwithpoorlydifferentiatedadenocarcinomasoradenocarcinomasofthediffusetype,accordingtoLauren’sclassification.Thisisduetothepossibilityofmetachronousorsynchronouspreneoplasticorneoplasticlesionsinotherpartsofthegastricmucosa.Incontrast,otherauthorsadvocatetheuseofDGduetoitslowermorbidity,mortality,providedthataminimumsafetymarginof3-cmcanbe5,guaranteed,regardlessofitsdifferentiationorLauren’sclassification.Thislackofsinglecriterionisevidentinthescientificliterature.Accordingtoareviewof62hospitalsinEurope.544%percentofsurgeonsoptedforTGincancerlocatedintheantrumthatishistologicallydefinedasdiffusefollowingLauren’sclassification.IntheUnitedStates,20%ofsurgeonswouldperformTGornear-totalgastrectomyinpatientswithdistalstomachcancer.6Morerecently,2studiesusingtheNationalCancerDataBaseasareference7,8showlowerfigures,closeto12%,althoughthepercentageapproaches40%iforgansotherthanthestomachareincludedintheresection.Itisevidentthat,indistalstomachcancers,TGcontinuestobeanapproachusedformanypatients,despitethefactthatDGissimplerfromatechnicalperspective,haslessmorbidityandmortalityand,moreimportantly,doesnotseemtohaveworseoncologicalresults.9–14Thismeta-analysisaimstoanalyzetheresultsintermsofefficacyinoncologicalsafety,morbidityandmortalityofDGversusTGinmiddle-thirdanddistalstomachcancer.Thelackofconsensusonthetwotechniquesjustifiestheneedforthisstudy.MethodsSearchstrategyThedatabasesincludedforthearticlesearchwerePubMed,CochraneandEMBASE,usingthesearchterms‘totalgastrectomy’,‘subtotalgastrectomy’,‘distalgastrectomy’,‘gastriccancer’and‘partialgastrectomy’.Allarticleswerereadby2independentreviewers.Intheabsenceofagreementbetweenbothreviewers,athirdpersonwasconsultedbeforerejectingorconsideringanarticleforthedatabase.InclusioncriteriaandstudyobjectivesTheselectioncriteriawere:1)articlewritteninEnglish,FrenchorSpanish;2)studiescomparingTGandDGinmiddle-thirdanddistalstomachcancerperformedforcurative,notpalliative,purposes;and3)retrospectiveandprospectivestudies.Theprimaryobjectivesofourmeta-analysiswere:5-yearsurvivalandperioperativemortality.Thesecondaryendpointswere:lymphnodesobtained,postoperativecomplications(intra-abdominalabscess,paralyticileus,postoperativehemorrhage),andanastomoticfistula.DatacollectionDatacollectionandsubsequentassessmentwerecarriedoutby2independentresearchers.Thefollowingvariableswereincludedforeachstudy:nameoftheauthors,yearofpublication,typeofstudy.Thefollowingvariableswereextractedfromeachofthestudygroups:numberofpatients,postoperativemortality,anastomoticfistula,postoperativecomplications(paralyticileus,postoperativehemorrhage,intra-abdominalabscess),numberoflymphnodesremoved,and5-yearsurvival.StatisticalanalysisThecomparativedataofthestudieswereexpressedasoddsratio(OR)witha95%confidenceinterval(CI).WeassessedtheheterogeneityofthestudieswiththeI-squaredindex(I2)andtheCochraneQtest(P).Whenheterogeneitywassignificant,weusedtherandom-effectsmodel.StatisticallysignificantdifferencesinheterogeneitywereconsideredwhenPI2>35%.Toassesstheexistenceofpublicationbias,afunnelplotwascreated.ResultsArticlesearchandselectionTheinitialsearchwiththekeywordsidentifiedatotalof4500articles.Theflowchart(Fig.1)illustratesthereasonsfordiscardingarticlesandreachingthe15selected.Theywerediscardedforthefollowing:nothavinganyrelationshipornotdealingwithsurgeryingastriccancer;notselectivelystudyingmiddleordistalgastriccancer;notcomparingbothtechniques;lackingadequatestatisticalmethodology;dealingwithqualityoflifeafterbothtechniqueswithoutincludingcomplicationsaftertheinterventions;becausetheywerewritteninlanguagesotherthanthosedesignatedintheinclusioncriteria;becausetheyincludedpatientswithdifferentsurgicaltechniquesornon-curativesurgeries;and,lastly,becausetheydidnotincludecertaindataonpostoperativemortalityormid-termsurvival. Fig.1.Flowchartofthearticlesearchandinclusionprocess.(0.2MB).Thecharacteristicsandvariablesofthe15studiesincluded15–29areshowninTable1.Table1.Characteristicsofthearticlesincludedinthemeta-analysis.5-yearsurvivalinTG    92(47)  99(38.4)    100(58.4)  33(37)    426(45.5)    9(22)  24(38.1)  82(48)  12(28.9)  11(42.2)  42(51)  Mean ± SDoflymphnodesobtainedinTG    32 ± 3.33  37.25 ± 9.83  48.2 ± 15.3  44.1 ± 16.89    38.3 ± 16.3  35 ± 13.6    35.5 ± 15.3        26.25 ± 4.75    PostoperativemortalityinTG  7(2.3)  3(1.5)  25(9.7)  0(0)    9(10.1)  0(0)  4(0.4)  1(1.3)  2(5)      4(9.5)    8(9.6)  AnastomoticdehiscenceinTG  8(2.6)  8(4.1)  10(3.9)  1(1.5)    8(9)  5(5.3)  11(1.1)  7(9.2)  1(2.5)          16(19.3)  ComplicationsinTG  26(8.6)  43(22.1)  33(12.8)  8(12)    26(29.2)  9(9.6)  73(7.5)  9(11.8)  2(5)          12(14.5)  PatientsinTG  304  195  258  67  178  89  94  976  76  40  63  171  42  26  83  5-yearsurvivalinDG    94(65)  34(43)    98(66.2)  53(58)    316(50.8)    28(36)  43(69)  672(86.4)  25(51.1)  12(58.2)  57(63)  Mean+/-SDlymphnodesobtainedinDG    26 ± 2.67  24 ± 9.67  40 ± 13.7  38.7 ± 16.62    33.6 ± 14.6  32.6 ± 11.1    31.2 ± 12.5        14.75 ± 2.25    PostoperativemortalityinDG  4(1.3)  0(0)  4(5)  0(0)    1(1.1)  4(0.7)  2(0.3)  3(3.2)  1(1.3)      2(4.1)    2(2.2)  AnastomoticdehiscenceinDG  3(0.9)  0(0)  3(3.8)  5(1)    1(1.1)  3(0.5)  5(0.8)  5(5.4)  1(1.3)          2(2.2)  ComplicationsinDG  23(7.2)  14(9.7)  1(1.3)  21(4.4)    7(7.7)  37(6.5)  40(6.2)  13(14)  6(7.8)          11(12.1)  PatientsinDG  320  144  80  473  148  91  569  646  93  77  62  778  49  20  91  Design  PR  R  R  R  R  R  R  R  PR  PnR  R  PnR  PnR  R  R    Bozzettietal.22  Xinetal.29  Gockeletal.16  Leeetal.17  Jangetal.18  Mocanetal.19  Kimetal.20  Linetal.21  Gouzietal.15  Manzonietal.23  Leeetal.24  Ogoshietal.25  Cenitagoyaetal.26  Areretal.27  Ambrosettietal.28  Thepercentagesofeachofthevariablesofthetotalnumberofpatientsareinparentheses.PnR:prospectivenotrandomized;PR:prospectiverandomized;R:retrospective.Resultsofthemeta-analysis15articleswithatotalof6303patientswerestudied(TG=2662;DG=3641).ComparedwiththepatientsintheTGgroup,thepatientsintheDGgrouppresentedfewercomplications(OR:0.58;95%CI:0.40-0.85;I2:86%)(Fig.2).Similarly,theappearanceofananastomoticfistulawassignificantlylowerintheDGgroup(OR:0.33;95%CI:0.18-0.61;I2:33%)(Fig.3).Withthese2data,theresultforpostoperativemortalitywasasexpected,withlowermortalityintheDGgroup(OR:0.44;95%CI:0.26-0.76;I2:0%)(Fig.4). Fig.2.ComparisonofthepostoperativecomplicationsofDGversusTG.(0.32MB). Fig.3.ComparisonofthenumberofanastomoticleaksofDGversusTG.(0.28MB). Fig.4.ComparisonofpostoperativemortalityofDGversusTG.(0.36MB).LymphadenectomyintheDGgroup(range15-40)obtainedalowernumberofnodesthantheTGgroup(range26-48),with7fewernodesonaverage(OR:−7.07;95%CI:[−9.54]-[−4.49];I2:93%)(Fig.5).However,removalofasmallernumberofnodesdidnotreducethemean5-yearsurvivalrateinthisgroup.Infact,thepatientswhounderwentDGhadhighersurvivalratescomparedtotheTGgroup(OR:2.15;95%CI:1.42-3.25;I2:87%)(Fig.6). Fig.5.ComparisonofthenumberoflymphnodesobtainedinDGversusTG.(0.29MB). Fig.6.Comparisonof5-yearsurvivalinDGversusTG.(0.41MB).ThesummaryofthecomparativestatisticsbetweenbothgroupsisshowninTable2.Table2.SummaryofthestatisticsobtainedfromthecomparisonbetweenDGandTG.Variables  OR(95%CI)    Heterogeneitytest        I2en%  τ2  P  Postoperativecomplications  0.58(0.40-0.85)  56  0.1893  0.02  Anastomoticleaks  0.33(0.18-0.61)  33  0.3014  0.15  Resectedlymphnodes  −7.07(−9.54-4.49)  93  11.4291  <0.01  Postoperativemortality  0.44(0.26-0.76)  0  0  0.66  5-yearsurvival  2.15(1.42-3.25)  87  0.3855  <0.01  DiscussionBackgroundforthemeta-analysisTodate,andtoourknowledge,nometa-analysishasbeenpublishedbyWesternauthorscomparingwhichgastrectomyshouldbeplannedformiddle-thirdanddistalstomachcancerintermsofpostoperativecomplicationsandmortality,withoutforgettingsafetyinoncologicalefficacy(5-yearsurvival).Fromastrictlysurgicalpointofview,thetypeofgastrectomyformiddleordistalstomachcancerisareasonfordivergenceofopinions,andourintentionwiththismeta-analysisistoshinesomelightonthispoorlydefinedpanorama.TherearesurgeonswhoroutinelyperformTGbecausetheyunderstandthatitdoesnotleadtogreatermorbidityandmortality,andbecausetheybelievethatpatientsurvivalwillbelonger.30TheyalsoassociateDGwithahigherrateofrecurrenceand,therefore,reoperations.Othersurgeons,ontheotherhand,aremorefamiliarwithDG,sinceTGwouldbeassociatedwithasignificantlyhighermorbidityandmortalityrate(closetodouble).31,32Accordingtothelatter,theJapaneseGastricCancerAssociationdefinesstandardgastrectomyasthatwhichhasacurativepurpose,whichwouldimplyaD2lymphadenectomyand,atleast,theresectionof2/3partsofthestomach,providedasufficientmarginisachieved(3cminexpansivegrowthtumorsand5cmininfiltrativegrowthtumors).33CharacteristicsofthestudiesincludedAtotalof2randomizedprospectivestudies,3non-randomizedprospectiveand10retrospectivestudieshavebeenincludedinthisstudy,withatotalof6303patients(3641DGand2662TG).Ingeneral,ithasalwaysbeenstatedthatundifferentiatedordiffusestomachcanceraccordingtoLauren’sclassification,regardlessoflocation,shouldalwaysbetreatedwithaTG.Surprisingly,wefoundthatinalltheseriesincludedinthismeta-analysisexceptone(theGockeletalstudy)16Lauren’sundifferentiatedordiffusecancerswerenotthereasonforexcludingDG.Eveninsomeseries,suchasthatbyLinetal,21upto84%ofDGwereinpatientswithundifferentiatedordiffusecancers.Althoughallseriesconsideradequatesurgicalmarginaninclusioncriterion,only5series16,18,19,22,29definedamarginrangingbetween3and6cmasvalid.Laparoscopicsurgeryforgastriccancerisgainingpresence.Thesameresultsareobtainedintermsofoncologicalradicalityandsurvival,withbetterhospitalstayparameters.34However,theyarecomplextechniquesand,therefore,fewgroupsincorporatethemintotheirroutineworkingastriccancer.Itisnotsurprisingthatonly3oftheincludedstudiescarriedoutlaparoscopicresections.17,20,21PostoperativecomplicationsOurmeta-analysisconfirmsthatafterDGthepatientis1.72timeslesslikelytopresentcomplicationsinthepostoperativeperiod.Thisdataisnotsurprisingwhenverifyingthat,inallseriesexceptone(Gouzietal15),complicationswerelowerintheDGgroup.ItshouldbenotedthatGouzietal(14%complicationsinDGand12%complicationsinTG–almostsimilar)definedinclusioncriteriafortheirveryrestrictivepatients:theyrejectedpatientswithchronickidneyorheartfailure,poorlycontrolleddiabetes,arteritis,bodyweightgreaterthan20%ofthemeanweightadjustedforageandsex,andlivercirrhosis.Inshort,theinclusionofpatientswhoaretechnicallysimpler(notobese)orhaveagreaterfunctionalreserve(withoutcomorbidities)couldjustifyasimilarrangeofcomplications,eveninmorelaboriousandcomplextechnicalproceduressuchasTG(inthissameseries,althoughthedatumisnotcollected,thereisacommentthattherewasagreaternumberofnecessarysplenectomiesintheTGgroup).AnastomoticfistulaTherevieweddatafromourmeta-analysisreflectthatthechancesofhavingananastomoticfistulaare3timeslowerafterDG.Thehigherprobabilityofdehiscenceafteresophagojejunalanastomosisisnotsurprising,sinceithasalwaysbeenarguedthatthisanastomosishasahigherriskofdehiscencerelatedtoischemiaortensionintheanastomosis.Whenitoccursearly,itisattributedtotechnicalerrors,especiallyduetothesuturingoftheesophagealwallaroundthestem.Itcanbepreventedbyadequatethoroughnessintechnicalstepsduringsurgery.Agreaterandbettervascularsupplyoftheremainingstomachcomparedtotheterminalesophagusintheanastomosisis,accordingtoGouzietal15(incidenceofanastomoticfistulacloseto10%),thedeterminingcauseofthelowerincidenceoffistulainpatientswithDG.Ambrosettietal,28whoreportedanincidenceoffistulacloseto20%intheTGgroup,consideritessentialthattotalgastrectomybereferredtoasurgeonwithalargenumberofcasesperyear,implyingthatfistulaearelargelyduetotechnicalerrors.PostoperativemortalityPostoperativemortalityinourmeta-analysiswas2.27timeslowerintheDGgroup.Amongthoseselected,2seriesstandoutinwhichmortalitywasclearlylowerintheDGgroup.19,28BothregisteredthehighestrateofanastomoticfistulaeintheTGgroup(9%and19%).Itisevidentthatmortalityinthese2serieswasdirectlyrelatedtotheanastomoticfistula.However,intheseriesbyGouzietal,15despiteahighincidenceofanastomoticfistulaintheTGgroup(closeto10%),mortalityinbothgroupswassimilar(2.4%).Thereasonforthisapparentdisparityisthatmorethan50%ofthefistulaeweresubclinical,diagnosedonradiologicalfollow-upstudies,andallweremedicallymanagedsuccessfully,withnomortality.Indeed,ananastomoticfistulaafteratotalgastrectomydoesnotalwaysimplythedeathofthepatient.Infact,in4seriesconsulted,15,19,20,28thenumberofdeathsinthepostoperativeperiodofTGwassignificantlylowerthanthenumberoffistulaethatoccurred.Thisemphasizestheimportanceofearlyandmultidisciplinarytreatmentofthiscomplicationtoavoidthedeathofthepatient.RadicaloncologicalsurgeryafterTGhasbeenrelatedtohighermortalityratesandisoneofthereasonswhyEuropeangroupshavediscouragedextendedD2lymphnodedissections,sooftenrecommendedamongJapanesesurgeons.33Alongthisline,theseriesbyGockeletal,16withamortalityof10%intheTGgroup,showedthatpancreaticfistula(8.8%)wasthemaincauseofdeath,surpassinganastomoticfistula(3.8%).Intheirseries,lymphadenectomywasroutinelyD2,andsplenectomyandleftpancreatectomywereperformedin63.7%and3.7%oftheirpatients,respectively.ResectedlymphnodesToday,mostsurgeonsleantowardsD2lymphnodedissection,albeitwithouttheenthusiasmofJapanesesurgeons,whoarecreditedwiththemostextensivelymphnodedissections.ItispossiblethatthisradicalityisalsogreatlyinfluencedbythephenotypeofJapanesepatients,whoarelessfrequentlyobeseand,therefore,easierfromatechnicalstandpoint.Inpatientswhoareoverweightortechnicallymorecomplexduetoanothercause,theminimumqualitystandardrequiredtoachievecorrectstagingofthetumorinvolvesresectingnofewerthan15nodes.Inaddition,thelatestchemotherapyandradiotherapyregimensprovideadditionaltreatmentstosurgery,whichcomplementandsupportthesedissectionsthatareperhapsinsufficientinthenumberoflymphnodes,accordingtothecriteriaoftheJapaneseschool.Intheseriesconsulted,theDGgrouphadasignificantlylowernumberofnodes(OR:−7.07;95%CI:[−9.54]-[−4.49];I2:93%),althoughitsrangeoflymphnodes(15-40)inthemeta-analysiscanbeconsideredadequateand,infact,wehaveseenthatthishasnotaffectedthelong-termsurvivalofthisgroup.Long-termsurvival75%oftheseriesconsulted(8/12)inthismeta-analysisdidnotshowdifferencesinlong-termsurvivalbetweenthe2groups,DGandTG.Indeed,almostallofthemestablishNstage,15,16,19,22,23,25–29Tstage,15,16,22,25andTNMstage,18,19,24,26–28asfundamentalpredictivefactorsforpoorsurvivalinthemultivariateanalysis,aswellas,inonlyoneseries,theextentoflymphadenectomy18orneoadjuvanttherapy,29withoutmentioningthetypeofgastrectomyperformed.InnoneoftheserieswastheLaurendiffusetypeorundifferentiatedadenocarcinomashowntobeapredictorforpoorprognosis.Now,thefinalresultofthemeta-analysis,includingthe4remainingseries,concludesthatthe5-yearsurvivalis2timeslongerintheDGgroup.Wewillanalyzethese4seriesindividually.IntheseriesbyOgoshietal,255-yearsurvivalfavorsDG(86.4%vs.48%),andtheyarguethatthegreatermarginobtainedafterTGandeventhegreaternumberofresectedlymphnodeswouldnotberelevanttosurvival.Onthecontrary,theyconsiderthatpreservingtheduodenum,withtheconsequentpassageoffoodthroughit,afterDG(75%Billroth1)wouldbeassociatedwithbetterimmunologicalconditions,lessweightlossandbetterregulationofgastrointestinalhormones,allofwhichareparametersassociatedwithimprovedqualityoflifeandgreatersurvival.IntheseriesbyLeeetal,24thedifferencesinfavorofDGwerealsobroad(69%vs.38%),althoughwithnostatisticalsignificanceafterthemultivariateanalysis.However,theyalsoinsistedonthebetternutritionalqualityoflifeofthesepatientsandthereforerecommendedDG,providedthatthemarginwasadequate.Cenitagoyaetal26claimthattheonlyreasontoexplainthebettersurvivalinDG(51%vs.29%)isthelocationofthetumor.Theymerelydescribehowtumorsofthemiddlethirdhaveaworseprognosis,althoughwithoutrelatingthislocationtotheother2variables,whichwereonlysignificantintheirseriesofpoorprognosisafterthemultivariateanalysis:lymphnodeinvolvementandTNMstage.Lastly,thesurvivalrate,whichwaswidelyfavorableforDGintheMocanseries19(58%vs.37%),wasonlysignificantinstageIBoftheTNMclassification.Inthemultivariateanalysisoftheglobalseries,thetypeofgastrectomywasnotsignificant,infavoroflymphnodeinvolvementandTNMstage.Limitationsofthemeta-analysisAlthoughthismeta-analysishasbeencarriedoutfollowingguidelinesforquality,wefoundaseriesoflimitations.First,only2ofthestudiesarerandomizedcontrolledclinicaltrialsand,interestingly,theyaretheoldest2includedinthemeta-analysis.Furthermore,only3havebeenpublishedinthelast5years,sotheimpactonsurvivalofneoadjuvanttreatmenthasbeenanalyzedinasingleseries.Second,thestudieshavebeencarriedoutinhospitalsincountriessuchasItaly,Germany,KoreaorChina,buttherearemanyothercountriesthathavenotbeenincludedinthestudy.Additionally,onlyarticleswritteninEnglish,FrenchandSpanishwereincluded,whichmayhaveleftoutarticlesonthistopicthatdidnotmeetthelanguagecriterion.Third,thesamplesizeof15seriesissmalland,furthermore,5ofthemdidnotincludemorbidity,surgicalmortalityor5-yearsurvivalamongtheirstudyvariables.Forthisreason,wefeelthatmorecontrolledandrandomizedclinicaltrialswithlargerpatientsampleswillbenecessaryinthefuturetodeterminetheadvantagesordisadvantagesthatDGandTGmaypresentinthetreatmentofdistalstomachcancer.ConclusionsOurmeta-analysisconcludesthatDGistheidealtechniqueinmiddle-thirdanddistalstomachcancer,regardlessofwhetheritisundifferentiatedordiffuseaccordingtoLauren’sclassification.Providedasufficientmargincanbeobtained,DGisassociatedwithlowerpostoperativemorbidityandmortalityrates.Althoughfewerlymphnodesareremoved,thequalitystandardof15nodesisreachedinthelymphnodedissection,whichisevenassociatedwithalonger5-yearsurvivalrate.Unfortunately,thelimitednumberofprospectiverandomizedstudiesinthismeta-analysisdetractsfromitsresultsand,therefore,theseconclusionsmustbeconsideredwithcaution.FundingThisstudyhasreceivednospecificfundingfrompublic,commercialornon-profitsources.ConflictofinterestNone. 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☆Pleasecitethisarticleas:DuránGiménez-RicoH,DiéguezAguirreL,RíosPérezL,Cardinal-FernándezP,CarusoR,FerriV,etal.Estudiocomparativoentrelagastrectomíatotalysubtotalenelcáncerdistaldeestómago:metaanálisisdeestudiosprospectivosyretrospectivos.CirEsp.2020;98:582–590. 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