Diaphragmatic stripping versus full-thickness diaphragmatic resection in cytoreductive surgery: a meta-analysis of the current evidence.

Purpose: The primary objective was to compare the intra- and postoperative outcomes of diaphragmatic stripping versus full-thickness diaphragmatic resection in patients with peritoneal carcinomatosis who underwent cytoreductive surgery.

Methods: According to the PRSIMA guidelines, a comprehensive literature search was conducted for studies comparing postoperative pulmonary complications as well as intra- and postoperative outcomes of diaphragmatic stripping versus full-thickness diaphragmatic resection in patients with peritoneal carcinomatosis necessitating cytoreductive surgery. Data from eligible studies were extracted, qualitatively assessed, and included in a meta-analysis. Odds ratios (ORs) and standardized mean differences (SMDs) with 95 per cent confidence intervals were calculated.

Results: Ten studies with 1325 patients were included in this meta-analysis. Diaphragmatic stripping was associated with lower incidence of pleural effusion (OR 0.47, 95% CI 0.35-0.63, p < 0.00001) and pneumothorax (OR 0.52, 95% CI 0.35-0.78, p = 0.002), less severe postoperative complications (Clavien-Dindo Grade ≥ 3) (OR 0.43, 95% CI 0.30-0.63, p < 0.0001), and shorter duration of surgery (SMD -0.31, 95% CI -0.54 - -0.08, p = 0.007). No significant differences were observed in postoperative subdiaphragmatic abscess occurrence, intraoperative blood loss, hospital- and ICU-stay, and 90-day mortality.

Conclusions: Diaphragmatic stripping leads to a significantly lower rate of postoperative pulmonary and severe complications compared to diaphragmatic full-thickness resection, while oncological outcomes do not appear to be worse. Larger trials with standardized study protocols and long-term survival data are needed to validate the results presented here.