Splenectomy versus splenic preservation in total gastrectomy for gastric cancer: a systematic review and meta-analysis comparing survival benefits and short-term complications

ABSTRACT

Background

There is an ongoing debate regarding the comparative merits of splenectomy (SP) and splenic preservation in the surgical management of gastric cancer. This systematic review and meta-analysis aims to shed light on potential differences in survival outcomes and postoperative complications associated with these two procedures.

Method

An exhaustive literature search was conducted across multiple databases, namely PubMed, Embase, Cochrane Library, and Web of Science. We utilized a random-effects model via RevMan 5.4 software to conduct a meta-analysis of the hazard ratios (HRs) and risk ratios (RRs) associated with SP and spleen preservation. Subgroup analyses were based on various attributes of the included studies. We employed funnel plots to assess publication bias, and sensitivity analysis was conducted to gauge the stability of the combined results. Both funnel plots and sensitivity analysis were performed using Stata 12.

Result

Our research incorporated 23 observational studies and three randomized controlled trials, involving a total of 6,255 patients. SP did not yield superior survival outcomes in comparison to splenic preservation, a conclusion that aligns with the combined results of the randomized controlled trials. No statistically significant difference in survival prognosis was observed between SP and splenic preservation, irrespective of whether the patients had proximal gastric cancer or proximal gastric cancer invading the stomach’s greater curvature. SP exhibited a higher incidence of all postoperative complications, notably pancreatic fistula and intraabdominal abscesses. However, it did not significantly differ from splenic preservation in terms of anastomotic leakage, incision infection, intestinal obstruction, intra-abdominal bleeding, and pulmonary infection. No significant difference in postoperative mortality between SP and splenic preservation was found. Funnel plots suggested no notable publication bias, and sensitivity analysis affirmed the stability of the combined outcomes.

Conclusion

Despite the lack of significant differences in certain individual complications and postoperative mortality, the broader pattern of our data suggests that SP is associated with a greater overall frequency of postoperative complications, without providing additional survival benefits compared to splenic preservation. Thus, the routine implementation of SP is not advocated.

Plain Language Summary

When doctors perform surgery for gastric (stomach) cancer, they sometimes remove the spleen, a procedure known as splenectomy (SP). However, there’s a debate on whether removing the spleen is better than preserving it. Our study aimed to compare these two methods in terms of patient survival and the risk of complications after surgery. To do this, we looked at data from 26 studies involving 6,255 patients. Our analysis was thorough, using advanced statistical methods to ensure accuracy. Here’s what we found: patients who had their spleen removed did not live longer than those who kept their spleen. Whether the cancer was just in the upper part of the stomach or had spread to the nearby large curve of the stomach, the survival rates were similar for both groups. Patients who underwent SP faced more postoperative complications, especially issues like pancreatic fistula and intra-abdominal abscesses. However, for some complications like leakage from the surgical joint, infection of the wound, bowel obstruction, internal bleeding, and lung infections, there was no significant difference between the two groups. The chances of dying post-surgery were similar whether patients had their spleen removed or not. Our findings suggest that routinely removing the spleen during gastric cancer surgery does not improve survival rates and is linked to more postoperative complications. Therefore, it may be better to avoid removing the spleen unless absolutely necessary.

KEYWORDS:

• Splenectomy
• splenic preservation
• gastric cancer
• survival benefits
• short-term complications

Declaration of financial/other relationships

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

The authors thank the Key Laboratory of Molecular Diagnostics and Precision Medicine for Surgical Oncology in Gansu Province and the DaVinci Surgery System Database (DSSD, www.davincisurgerydatabase.com) for their assistance in the methodology and meta-analysis process.

Author contributions

Conception and design of the study: Hui Cai; Statistical analyses: Da Wang; Xiaohua Dong; Shuo Liu; Tianyi Liao; Supervision: Miao Yu; Hui Cai; Writing e original draft: Da Wang; Jingyao Ren; Lihui Zhu; Writing e-review and editing: Da Wang; Yuanyuan Wang; all authors reached an agreement to submit for publication.

Ethics statement

Informed consent has been obtained from all individuals included in this study. The conducted research is not related to either human or animal use.

Data availability statement

All data generated or analyzed during this study are included in this published article.

Additional information

Funding

This work was supported by grants from the 2021 Central-Guided Local Science and Technology Development Fund（ZYYDDFFZZJ-1), Gansu Provincial Youth Science and Technology Fund Program (21JR7RA642), Gansu Provincial Hospital project (2019-206), Lanzhou talent innovation and Entrepreneurship Project (2016-RC-56), and the Non-profit Central Research Institute Fund of Chinese Academy of Medical Sciences (21GSSYC-2).