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

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%, I 2 = 0), while in Siewert I tumors it was more heterogeneous (DP = 18%, I 2 = 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.