Critical appraisal of ‘comparison of laparoscopic versus open oesophagogastric devascularisation with splenectomy in portal hypertension: A meta-analysis’

Dear Editor, The recent meta-analysis by Zhang aimed to evaluate the efficacy and safety of laparoscopic versus open oesophagogastric devascularisation with splenectomy (OGDS) in patients with portal hypertension.[1] This review included 17 randomised controlled trials (RCTs) with a total of 1326 patients and addressed a clinically relevant question in the era of minimally invasive surgery. A major strength of this study lies in its broad literature search, encompassing both international and Chinese databases over more than four decades. The inclusion criteria were appropriate, focusing exclusively on RCTs in patients with cirrhotic portal hypertension. The analysis, performed using RevMan 5.3 software,[1] incorporated meaningful clinical outcomes such as intraoperative blood loss, operative duration, time to oral intake, complication rates and hospital costs. The findings generally favoured the laparoscopic approach, showing benefits such as reduced blood loss, quicker return to oral intake, decreased drainage volume, earlier ambulation, shorter hospital stay and fewer complications. These findings align with known advantages of laparoscopy, including reduced surgical trauma and enhanced recovery. However, several methodological issues undermine the robustness of these conclusions. Notably, the study did not assess the quality of evidence using the GRADE approach, which is a standard requirement for systematic reviews and meta-analyses in accordance with EQUATOR guidelines.[2] In addition, the pooled analyses showed substantial heterogeneity (I2 >90%) across nearly all outcomes, yet the author did not conduct subgroup or sensitivity analyses to explore the sources of this variation. Factors such as differences in surgical technique, perioperative protocols and patient selection could have contributed significantly to the observed heterogeneity. Risk of bias assessment was also insufficient. Although the Cochrane risk-of-bias tool was mentioned, detailed domain-specific evaluations (randomisation, allocation concealment, blinding and attrition) were not reported. Moreover, publication bias was assessed solely with a funnel plot, without statistical testing such as Egger’s test, despite the small number of studies per comparison. From an economic reporting perspective, the inclusion of hospital cost data fails to meet CHEERS 2022 standards.[3] The costing perspective (hospital, patient and societal), currency, price date and inflation adjustment were not specified. In addition, the outcome labelled ‘hospital cost’ was mistakenly referred to as ‘diet recovery time’ in Figures 9 and 11 and related text, likely a typographical translation error, which further reduces clarity.[1] The study also lacked discussion of important limitations, including the absence of long-term outcomes (e.g. rebleeding and hepatic function), patient-reported outcomes and technical variability between centres. Most included trials were from Chinese institutions, potentially limiting the global generalisability of the findings due to differences in surgical practice and healthcare infrastructure. In summary, while Zhang presents evidence suggesting laparoscopic OGDS may be superior to open surgery in selected patients, the high heterogeneity, insufficient bias assessment and lack of standardised economic reporting require cautious interpretation. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.