Total gastrectomy with splenectomy versus total gastrectomy with spleen preservation for gastric cancer

RATIONALE: Extended lymphadenectomy (extensive surgical removal of lymph nodes) demonstrates a survival benefit for patients undergoing gastrectomy (surgical removal of all or part of the stomach) for gastric cancer. Splenectomy (surgical removal of the spleen) is performed primarily for complete removal of the lymph nodes near the spleen during total gastrectomy. However, the role of routine splenectomy during total gastrectomy for gastric cancer is controversial. OBJECTIVES: To evaluate the benefits and harms of splenectomy in participants undergoing total gastrectomy for gastric cancer. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and two trials registers, together with reference checking, and we contacted study authors to identify studies for inclusion in the review. The latest search date was 17 February 2025. ELIGIBILITY CRITERIA: We included randomized controlled trials (RCTs) comparing splenectomy with spleen preservation in adults undergoing total gastrectomy for gastric cancer. We excluded quasi-randomized studies and non-randomized studies. OUTCOMES: Critical outcomes were overall survival, disease-free survival, and incidence of postoperative mortality. Important outcomes were incidence of postoperative complications, incidence of reoperation, length of hospital stay, and health-related quality of life after surgery. RISK OF BIAS: We used the Cochrane Risk of bias 1 tool (RoB 1) to assess the risk of bias in RCTs. SYNTHESIS METHODS: We synthesized results for each outcome in a meta-analysis using the random-effects model where possible or used the Synthesis Without Meta-analysis (SWiM) approach when it was not possible to undertake a meta-analysis of effect estimates. We used GRADE to assess the certainty of evidence for each outcome. INCLUDED STUDIES: We included five RCTs with a total of 1002 adult participants undergoing total gastrectomy: 498 participants were randomized to the splenectomy group and 504 to the spleen-preservation group. The studies were conducted in Asia and South America, and were published between 1985 and 2017. All studies were at overall high risk of bias. SYNTHESIS OF RESULTS: We considered the certainty of the evidence to be low or very low for all the outcomes except for incidence of postoperative complications, which was moderate certainty. We downgraded evidence certainty mainly due to high risk of bias and imprecision. Compared with spleen preservation for adults undergoing total gastrectomy, splenectomy may result in little to no difference in overall survival (hazard ratio (HR) 1.04, 95% confidence interval (CI) 0.81 to 1.33; 2 RCTs, 712 participants; low-certainty evidence) and disease-free survival (HR 1.15, 95% CI 0.85 to 1.54; 1 RCT, 505 participants; low-certainty evidence). The evidence is very uncertain about the effect of splenectomy compared with spleen preservation on the incidence of postoperative mortality (risk ratio (RR) 1.23, 95% CI 0.40 to 3.71; 5 RCTs, 1002 participants; very low-certainty evidence), Moderate-certainty evidence suggests that splenectomy probably increases the incidence of postoperative complications compared with spleen preservation in participants undergoing total gastrectomy (RR 1.80, 95% CI 1.33 to 2.45; 2 RCTs, 712 participants). Approximately 259 (192 to 353 participants) out of 1000 participants in the splenectomy group are likely to develop postoperative complications compared with 144 out of 1000 participants in the spleen-preservation group. The evidence is very uncertain about the effect of splenectomy compared with spleen preservation on the incidence of reoperation (RR 1.06, 95% CI 0.51 to 2.23; 2 RCTs, 692 participants; very low-certainty evidence), and length of hospital stay (two studies, 394 participants; very low-certainty evidence). The studies did not report health-related quality of life after surgery. AUTHORS' CONCLUSIONS: For the comparison of splenectomy versus spleen preservation in adult participants undergoing total gastrectomy for gastric cancer, moderate-certainty evidence suggests that splenectomy probably increases the incidence of postoperative complications. The evidence is very uncertain whether splenectomy increases postoperative mortality, incidence of reoperation, or length of hospital stay. Low-certainty evidence suggests that splenectomy may result in little to no difference in overall survival and disease-free survival. More studies are necessary to evaluate the benefits and harms of splenectomy in which participants are stratified according to the tumor locations and clinical stages. FUNDING: This Cochrane review was funded by the National Natural Science Foundation of China (Grant No. 81701950, 82172135), Natural Science Foundation of Chongqing (Grant No. CSTB2022NSCQ-MSX0058), Suitable Technology Promotion Project of Chongqing (Grant No. 2024jstg028), Joint Project of Pinnacle Disciplinary Group, and the Kuanren Talents Program of the Second Affiliated Hospital of Chongqing Medical University. REGISTRATION: Protocol (2021) DOI:10.1002/14651858.CD014601.