Oncologic and perioperative outcomes of laparoscopic versus open gastrectomy for T4a gastric cancer: A systematic review and meta-analysis.

BACKGROUND: The role of laparoscopic gastrectomy (LG) in T4a gastric cancer remains controversial because of concerns regarding oncologic adequacy and peritoneal dissemination. We compared LG with open gastrectomy (OG) in T4a gastric cancer. METHODS: PubMed, Embase, and Cochrane databases were searched from inception to February 2026. Primary outcomes were 5-year overall survival (OS) and disease-free survival (DFS). Random-effects meta-analyses used hazard ratios (HR), odds ratios (OR), and mean differences (MD) with 95% confidence intervals (CI). RESULTS: Thirteen studies were included (2 randomized trials and 11 non-randomized cohorts). Five-year OS (HR 0.95, 95% CI 0.85-1.07) and DFS (HR 0.91, 95% CI 0.79-1.04) did not differ significantly overall; a gastrectomy-type interaction was observed for 5-year OS (P = 0.0041), with imprecise subgroup estimates. Total, peritoneal, and hematogenous/liver recurrence did not differ. Locoregional recurrence showed a significant gastrectomy-type interaction (P < 0.0001). LG was associated with less blood loss, earlier flatus and oral intake, shorter hospital stay, and longer operative time. Pancreatic fistula was more frequent after LG (OR 2.19, 95% CI 1.05-4.58); other major safety outcomes did not differ significantly. CONCLUSIONS: In selected patients with T4a gastric cancer, LG was associated with similar long-term survival and recurrence outcomes to OG, with faster recovery but more pancreatic fistula. These findings support LG as a reasonable option in experienced centers, while the predominantly observational evidence warrants cautious interpretation.