Laparoscopy-assisted total gastrectomy has been increasingly performed even though it is always considered technically demanding [28]. In LATG, the digestive tract reconstruction is performed through a 5–7 cm small incision in the middle-upper abdomen [29–31]. It has been reported that TLTG has the advantages of less invasive than LATG [32, 33]. However, totally laparoscopic total gastrectomy (TLTG) for gastric cancer has not been generalized because of its technical difficulties and lack of short-term results. So, we performed this meta-analysis to compare the feasibility and safety of TLTG with LATG for gastric cancer.
The postoperative complication is a key index to evaluate the safety and technical feasibility of the surgical procedure. This study demonstrated no significant differences between TLTG and LATG groups in terms of overall postoperative complication rate. The major difference between TLTG and LATG is the methods of digestive tract reconstruction after lymphadenectomy. Therefore, we further analyze the incidence of anastomotic leakage and anastomotic stricture. In this study, the incidence of anastomotic stricture in the TLTG group was ranging from 0 to 10%. Kim et al[34] reported that the use of 45-mm linear staplers during the procedure of side-to-side esophagojejunostomy could create a stoma larger than 30-mm diameter, which therefore reduces anastomotic stricture. Ito et al [21]found there was no significant difference among the TLTG and LATG groups in the incidence of anastomotic stricture. Kim EY et al [23]did not observe anastomotic strictures, even after a long-term follow-up. The present study showed no significant differences between the two groups in terms of anastomosis-related complications. Intracorporeal esophagojejunostomy (IEJ) styles during the procedure of TLTG are various [35–38]. In this study, IEJ styles were liner staple and Orvil™. However, we could not perform subgroup analysis according to IEJ styles due to the limitation of sample size. Because the IEJ can be difficult, some researchers believe that TLTG was associated with longer operation time [27]. In this meta-analysis, the operation time for TLTG was shorter than LATG. Based on the further analysis of anastomotic time, our result showed that IEJ did not shorten the operation time. However, this result was not consistent among the included studies. In this study, the anastomotic time in the TLTG group was ranging from 18.6 to 47.5 min. Lu et al [25] reported that IEJ can shorten the operation time by 6 min when compared with extracorporeal esophagojejunostomy (EEJ). Conversely, Chen et al [22] found that the TLTG would take a longer time by 15 min as compared with LATG. As we all know, operation time was always affected by the learning curve. The skillful surgeons are capable of performing the operation safer and faster than unskilled surgeons. Previous studies have demonstrated that 20 to 40 cases are needed to overcome the initial learning curve of TLDG even for surgeons with sufficient experience in LADG [39, 40]. After completion of the learning for TLDG, the surgeon extended the technique from TLDG to include TLTG. In this study, the included studies did not clearly state the learning stage and experience of surgeons. So, we could not perform subgroup analysis based on different learning stage and surgeon’s experience.
This study showed that the estimated blood loss in the TLTG group was significantly lower than that in the LATG group. This might be attributed to TLTG does not need additional mini-laparotomy. Meanwhile, blood vessels in the muscles and mesentery can be more readily identified and are less likely to be transacted during the IEJ [27]. Moreover, the esophageal stump should be pulled out from the abdominal cavity when EEJ is performed. Chen et al [22]stated that the pulling puts great pressure on the esophageal stump and might even cause tearing and bleeding of the spleen envelope. However, we aware that the heterogeneity between studies was high and therefore this result should be interpreted prudently.
In terms of postoperative recovery outcomes, the TLTG group showed the earlier time to first flatus and oral intake. Meanwhile, we also found that the TLTG group was associated with shorter postoperative hospital stay though it failed to reach statistically significant. These results suggest that TLTG might a less invasive surgical procedure than LATG.
Theoretically, long-term survival outcomes are a critical measure to evaluate oncological outcomes. In the present meta-analysis, the number of the retrieved lymph nodes and the proximal resection margin is considered as the major indicators of oncological surgical quality due to limited studies included reported the outcomes of long‑term follow-up. Chen et al [22] found that the number of harvested lymph nodes of TLTG was more than that of LATG with a marginal difference (P = 0.06). In this meta-analysis, our result also revealed a tendency favoring the TLTG group though it failed to reach statistically significant. Logically, TLTG and LATG were similar in the procedure of lymphadenectomy. The marginal difference might because some surgeons perform LATG during their early period. In clinical practice, TLTG was usually performed by surgeons experienced in LATG. Our result showed that the length of the proximal resection margin was similar between the two groups. But this result was in high heterogeneity among the included studies. Gong et al [26] reported a shorter proximal margin in the TLTG group compared with the LATG group. We argued that such a result may relate to the fact that linear staplers are often placed on either side of the resection line and therefore might hinder the evaluation of the surgical margin. Kim et al[24] also found the length of the proximal margin was shorter in TLTG than in the conventional LATG, but the resection margins were free of tumor. Studies conducted by Chen et al and Lu et al demonstrated no significant difference between TLTG and LATG groups. These results suggest that TLTG can also achieve an adequate resection distance.
There are several limitations in the present study. First, all the included studies were retrospective and conducted in single-center from East Asia, which may have a bias in patients selection, surgeons experience, and regional differences, etc. Second, high heterogeneity was observed in some outcomes such as estimated blood loss, operative time, time to first flatus, and postoperative hospital stay. Additionally, limited data were available on long-term survival and quality of life, so we cannot perform further analysis.