Oncologic effectiveness and safety of splenectomy in total gastrectomy for proximal gastric carcinoma: Meta-analysis of randomized controlled trials

Background/Aim: The role of splenectomy as an essential component of radical surgery for proximal gastric cancer, from an oncological point of view, is still debated, and no consistent recommendations have been proposed. The aim of this systematic review with meta-analysis was to provide a more robust answer regarding the oncological effectiveness and safety of splenectomy in total gastrectomy for proximal gastric carcinoma. Materials and Methods: A systematic review and meta-analysis of randomized controlled trials was planned and performed in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and Cochrane Handbook for Systematic Reviews of Intervention. Patients with a histological diagnosis of gastric adenocarcinoma located in the upper third of the stomach who underwent D2 total gastrectomy with or without splenectomy were selected. The primary outcome was to analyze the influence of splenectomy on the overall survival of patients. Additionally, the mean difference in procedure time, length of hospital stay, number of retrieved lymph nodes, as well as the odds ratio of postoperative complications comparing splenectomy to spleen preservation were investigated in a secondary analysis Results: Overall, four studies with a total of 978 patients met the inclusion criteria. The pooled analysis showed no difference in overall survival rates between those who underwent spleen preservation compared to the splenectomy-treated group (risk ratio=0.92, 95% confidence interval=0.79 to 1.06, p=0.277). Interestingly, all studies reporting overall morbidity data highlighted statistically significant differences in favor of spleen-preservation group (odds ratio=2.11, 95% confidence interval=1.44 to 3.09, p<0.001). Conclusion: In total, gastrectomy for proximal gastric cancer, splenectomy should not be recommended as it increases operative morbidity without improving survival when compared to spleen preservation. Furthermore, our results may help in planning the updated versions of Gastric Cancer Treatment Guidelines. This meta-analysis, however, points to the urgent need for high-quality, well-designed, large-scale, clinical trials, with short-as well as long-term evaluation comparing splenectomy with spleen-preserving procedures, in a controlled randomized manner to help future research and to establish an evidence-based approach to gastric cancer treatment.