Staging laparoscopy in esophagogastric junction cancer: Systematic review and meta-analysis

Abstract

BACKGROUND

Staging laparoscopy (SL) is a valuable tool for detecting occult peritoneal or hepatic metastases in patients with gastroesophageal junction (GEJ) cancer, especially when imaging suggests resectability. Despite advances in cross-sectional imaging methodologies such as computed tomography, positron emission tomography/computed tomography and endoscopic ultrasound, these techniques may miss low-volume or superficial peritoneal disease. Early identification of metastatic spread through SL can avoid unnecessary surgery, reduce morbidity, and improve treatment planning. However, its use in GEJ tumors - particularly Siewert types I and II - remains debated. Understanding the diagnostic performance (DP) of SL is essential for optimizing staging strategies.

AIM

To evaluate the DP of SL in identifying abdominal metastatic disease in patients with clinically resectable GEJ tumors.

METHODS

Systematic review and meta-analysis in accordance with PRISMA 2020 guidelines. A comprehensive PubMed search was performed up to March 29, 2024, using Medical Subject Headings terms related to GEJ, laparoscopy, and cancer staging. Inclusion criteria: Studies assessing SL in patients with GEJ tumors. Primary outcome was the rate of upstaging to stage IV due to peritoneal or hepatic metastases. Secondary outcomes included details on techniques, patient characteristics, and procedural factors. Risk of bias was evaluated using Risk of Bias in Non-randomised Studies of Interventions and certainty of evidence with Grading of Recommendations, Assessment, Development and Evaluation.

RESULTS

Eighteen studies involving 1591 patients were included. SL upstaged 22% of patients (95% confidence interval: 17-27) to stage IV due to occult metastatic disease. The pooled positivity rates were positive peritoneal malignancy (17.5%), peritoneal carcinomatosis (13%), malignant peritoneal cytology (9%), and hepatic metastases (9.2%). SL avoided unnecessary surgery in 19.8% of cases. Subgroup analysis revealed consistent performance in Siewert II tumors (DP = 13%, I² = 0), while in Siewert I tumors it was more heterogeneous (DP = 18%, I² = 93.7%). Only five studies reported complications, mostly minor, with no procedure-related mortality. No comorbidities, carcinomatosis scoring, conversion to open surgery, complications of follow-up, readmissions, postoperative length of stay, or delay in initiating neoadjuvant therapy were recorded.

CONCLUSION

SL improves staging accuracy in GEJ cancers, especially Siewert II. Despite heterogeneity and limited data stratification, SL may guide therapeutic decisions and help avoid unnecessary or futile surgeries.

Keywords: Esophagogastric junction; Laparoscopy; Neoplasm staging; Staging laparoscopy; Systematic review; Meta-analysis

Core Tip: Staging laparoscopy (SL) upstaged nearly one in five patients with clinically resectable gastroesophageal junction cancer by revealing occult peritoneal or hepatic metastases. This finding underlines the value of SL in refining staging and guiding treatment decisions. Diagnostic performance was especially high in Siewert II tumors, without any significant heterogeneity. However, key procedural and patient-related data were not appropriately reported across studies. These results support the routine use of SL in staging gastroesophageal junction tumors and highlight the urgent need for standardized reporting to improve risk stratification and clinical outcomes in this challenging and heterogeneous cancer subgroup.