Open, laparoscopic, versus robotic surgery for Siewert type II/III adenocarcinoma of esophagogastric junction: A systematic review and Bayesian network meta-analysis.

Abstract

e16093 Background: The optimal surgical approach for Siewert type II/III adenocarcinoma of the esophagogastric junction (AEG) remains debated, with open, laparoscopic, and robotic techniques each in use. Direct comparative evidence, particularly for robotic gastrectomy, is scarce. This study aimed to comprehensively evaluate the efficacy and safety of these three modalities. Methods: A systematic review and Bayesian network meta-analysis were conducted following PRISMA guidelines. Four databases were searched through November 2025 for studies comparing open, laparoscopic, and robotic surgery for Siewert II/III AEG. Pairwise and network meta-analyses were performed, with outcomes pooled as odds ratios (RR) or mean differences (MD) with 95% confidence (CI) or credible intervals (CrI). Treatment rankings were estimated using the Surface Under the Cumulative Ranking Curve (SUCRA). Results: Fifteen studies (1847 laparoscopic, 1399 open, 56 robotic cases) were included. Pairwise meta-analysis demonstrated laparoscopic surgery offered significant advantages over open surgery: reduced intraoperative blood loss (MD: -92.09 mL, 95% CI: -128.07 to -56.12), shorter hospital stay (MD: -1.98 days, 95% CI: -2.13 to -1.83), fewer overall complications (RR: 0.79, 95% CI: 0.66 to 0.94), and improved 5-year overall survival (RR: 1.33, 95% CI: 1.06 to 1.67). Open surgery maintained superiority in lymph node yield (MD: 1.38 nodes, 95% CI: 0.23 to 2.54). Compared to laparoscopy, robotic surgery was associated with higher lymph node retrieval (MD: 5.39 nodes, 95% CI: 0.36 to 10.41) and lower blood loss (MD: -32.44 mL, 95% CI: -55.16 to -9.72). The Bayesian network meta-analysis provided a comparative hierarchy: Robotic surgery ranked highest (best) for minimizing blood loss (SUCRA 82.5%), reducing overall complications (SUCRA 88.7%), achieving the lowest anastomotic leakage rate (SUCRA 99.7%), and enabling the shortest hospital stay (SUCRA 90.9%). Open surgery ranked highest for thorough lymphadenectomy (SUCRA 98.5%) and shortest operative time (SUCRA 81.6%). Laparoscopic surgery was ranked most favorable for reducing postoperative ileus risk (SUCRA 89.7%). No statistically significant differences in mortality were observed between the three approaches. Conclusions: While open surgery remains the benchmark for lymphadenectomy and operative efficiency, minimally invasive approaches offer distinct benefits. Laparoscopic surgery provides reliable recovery advantages. Robotic surgery emerges as promising for superior perioperative safety, particularly regarding anastomotic integrity, though these findings require validation in larger prospective studies. The surgical approach should be individualized based on tumor factors, expertise, and resources.