Robotic versus open approach in total gastrectomy for gastric cancer: a comparative single-center study of perioperative outcomes

The robotic approach to gastric cancer has been gaining interest in recent years; however, its benefit over the open procedure in total gastrectomy with D2 lymphadenectomy is still controversial. The aims of the study were to compare postoperative morbidity and mortality, hospital stay, and anatomopathological findings between the robotic and open approaches to oncologic total gastrectomy. We analyzed a prospectively collected database, which included patients who underwent total gastrectomy with D2 lymphadenectomy in our center using a robotic or an open approach between 2014 and 2021. Comparative analysis of clinicopathological, intraoperative, postoperative and anatomopathological variables between the robot-assisted group and the open group was performed. Thirty patients underwent total gastrectomy with D2 lymphadenectomy by a robotic approach and 48 patients by an open procedure. Both groups were comparable. The robot-assisted group presented a lower rate of Clavien-Dindo complications ≥ stage II (20 vs. 48%, p = 0.048), a shorter hospital stay (7 days vs. 9 days, p = 0.003) and had a higher total number of lymph nodes resected (22 nodes vs. 15 nodes, p = 0.001) compared to the open approach. Operative time was longer in the robotic group (325 min vs. 195 min, p < 0.001) compared to the open group. The robotic approach is associated with a longer surgical time, a lower rate of Clavien-Dindo complications ≥ stage II and a shorter hospital stay, and more lymph nodes were resected compared to the open approach.

Robotic versus open oncological gastric surgery in the elderly: a propensity score-matched analysis

Although there is no agreement on a definition of elderly, commonly an age cutoff of ≥ 65 or 75 years is used. Even if robot-assisted surgery is a validated option for the elderly population, there are no specific indications for its application in the surgical treatment of gastric cancer. The aim of this study is to evaluate the safety and feasibility of robot-assisted gastrectomy and to compare the short and long-term outcomes of robot-assisted (RG) versus open gastrectomy (OG). Patients aged ≥ 70 years old undergoing surgery for gastric cancer at the Department of Surgery of San Donato Hospital in Arezzo, between September 2012 and March 2017 were enrolled. A 1:1 propensity score matching was performed according to the following variables: age, Sex, BMI, ASA score, comorbidity, T stage and type of resection performed. 43 OG were matched to 43 RG. The mean operative time was significantly longer in the RG group (273.8 vs. 193.5 min, p < 0.01). No differences were observed in terms of intraoperative blood loss, an average number of lymph nodes removed, mean hospital stay, morbidity and mortality. OG had higher rate of major complications (6.9 vs. 16.3%, OR 2.592, 95% CI 0.623–10.785, p = 0.313) and a significantly higher postoperative pain (0.95 vs. 1.24, p = 0.042). Overall survival (p = 0.263) and disease-free survival (p = 0.474) were comparable between groups. Robotic-assisted surgery for oncological gastrectomy in elderly patients is safe and effective showing non-inferiority comparing to the open technique in terms of perioperative outcomes and overall 5-year survival.

A New Robot-assisted Billroth-I Reconstruction: Details of the Technique and Early Results

BACKGROUND

Laparoscopic surgery for gastric tumor is considered a demanding procedure because of lymph node dissection and reconstruction. Billroth-I (B-I) reconstruction after laparoscopic distal gastrectomy is commonly performed extracorporeally because of the complexity of an intracorporeal procedure. Robotic surgery overcomes some limitations of laparoscopy, allowing to reproduce the basic maneuvers of open surgery. We describe a new technique to perform robotic B-I anastomosis.

METHODS

Between January 2012 and February 2015, 5 patients underwent distal gastrectomy with intracorporeal B-I-stapled anastomosis. Patient demographics, tumor characteristics, histopathologic features, and perioperative data were analyzed.

RESULTS

Median operative time was 170 minutes (145 to 180 min). There were no conversions. Contrast swallow was routinely performed on the third postoperative day. Median postoperative hospitalization was 7 days (range: 6 to 8). No major complications or mortality were observed.

CONCLUSIONS

Robotic distal gastrectomy with intracorporeal B-I anastomosis is a safe and promising technique in selected cases of gastric tumors.

Perioperative outcomes of robotic surgery for the treatment of lung cancer compared to a conventional video-assisted thoracoscopic surgery (VATS) technique

Aim

To conduct a meta-analysis to determine the relative merits between robotic video-assisted thoracoscopic surgery (R-VATS) and conventional video-assisted thoracoscopic surgery (VATS) for lung cancer.

Results

Fifteen studies matched the selection criterion, which reported 8827 subjects, of whom 1704 underwent R-VATS and 7123 underwent VATS. Compared the perioperative outcomes with VATS, reports of R-VATS indicated unfavorable outcomes considering the operative time (SMD = 0.48, 95% CI 0.15 to 0.81). Meanwhile, the number of dissected lymph nodes (SMD = 0.12, 95% CI -0.27 to 0.51) and hospital stay following surgery (SMD = -0.1; 95% CI -0.27 to 0.07), conversion (RR = 0.68; 95% CI 0.42 to 1.11), morbidity (RR = 0.99, 95% CI 0.92 to 1.07) and mortality (RR = 0.33, 95% CI 0.1 to 1.09) were similar for both procedures.

Materials and Methods

A literature search was performed to identify comparative studies reporting perioperative outcomes for R-VATS and VATS for lung cancer. Pooled risk ratio (RR) and standardized mean differences (SMDs) with 95% confidence intervals (95% CIs) were calculated using either the fixed effects model or the random effects model.

Conclusions

There is no difference in terms of perioperative outcomes between R-VATS and VATS except for the operative time which is significantly high for R-VATS. Further studies are required to confirm these results.

Robotic gastrectomy for gastric cancer

The number of robotic gastrectomy (RG) performed per year has been increasing, particularly in East Asia where the incidence of gastric cancer is high and approximately half of the cases are diagnosed as early gastric cancer. With articulated devices of RG, surgeons are able to perform every procedure more meticulously, which can result in less bleeding and damage to organs. There are many single arm and comparative studies, and these study showed similar trends, which included relatively less estimated blood loss and longer operation time following RG than laparoscopic gastrectomy (LG), equivalent number of harvested lymph nodes and similar length of postoperative hospital stay between RG and LG. Considering the results of these retrospective comparative studies, RG seems to be as feasible as LG in terms of early surgical outcomes. However, medical expense of RG is approximately twice as much as that of LG. Lack of solid evidence in terms of long-term outcomes is another problem. Considering the higher medical expenses associated with RG, its superiority in terms of long-term survival outcomes needs to be confirmed in the future for it to be accepted more widely.

Robot-assisted surgery in elderly and very elderly population: our experience in oncologic and general surgery with literature review

BACKGROUND

Although there is no agreement on a definition of elderly, commonly an age cutoff of ≥65 or 75 years is used. Nowadays most of malignancies requiring surgical treatment are diagnosed in old population. Comorbidities and frailty represent well-known problems during and after surgery in elderly patients. Minimally invasive surgery offers earlier postoperative mobilization, less blood loss, lower morbidity as well as reduction in hospital stay and as such represents an interesting and validated option for elderly population. Robot-assisted surgery is a recent improvement of conventional minimally invasive surgery.

AIMS

We provided a complete review of old and very old patients undergoing robot-assisted surgery for oncologic and general surgery interventions.

PATIENTS AND METHODS

A retrospective review of all patients undergoing robot-assisted surgery in our General Surgery Unit from September 2012 to June 2016 was conducted. Analysis was performed for the entire cohort and in particular for three of the most performed surgeries (gastric resections, right colectomy, and liver resections) classifying patients into three age groups: ≤64, 65-79, and ≥80. Data from these three different age groups were compared and examined in respect of different outcomes: ASA score, comorbidities, oncologic outcomes, conversion rate, estimated blood loss, hospital stay, geriatric events, mortality, etc.

RESULTS

Using our in-patient robotic surgery database, we retrospectively examined 363 patients, who underwent robot-assisted surgery for different diseases (402 different robotic procedures): colorectal surgery, upper GI, HPB, etc.; the oncologic procedures were 81%. Male were 56%. The mean age was 65.63 years (18-89). Patients aged ≥65 years represented 61% and ≥80 years 13%. Overall conversion rate was of 6%, most in the group 65-79 years (59% of all conversions). The more frequent diseases treated were colorectal surgery 43%, followed by hepatobilopancreatic surgery 23.4%, upper gastro-intestinal 23.2%, and others 10.4%.

DISCUSSION

Robot-assisted surgery is a safe and effective technique in aging patient population too. There was no increased risk of death or morbidity compared to younger patients in the three groups examined. A higher conversion rate was observed in our experience for patients aged 65-79. Prolonged operative time and in any cases steep positions (Trendelenburg) have not represented a problem for the majority of patients.

CONCLUSIONS

In any case, considering the high direct costs, minimally invasive robot-assisted surgery should be performed on a case-by-case basis, tailored to each patient with their specific histories and comorbidities.

Intraoperative Endoscopic Botox Injection During Total Esophagectomy Prevents the Need for Pyloromyotomy or Dilatation

BACKGROUND

Esophagectomy may lead to impairment in gastric emptying unless pyloric drainage is performed. Pyloric drainage may be technically challenging during minimally invasive esophagectomy and can add morbidity. We sought to determine the effectiveness of intraoperative endoscopic injection of botulinum toxin into the pylorus during robotic-assisted esophagectomy as an alternative to surgical pyloric drainage.

MATERIALS AND METHODS

We performed a retrospective analysis of patients with adenocarcinoma and squamous cell carcinoma of the distal esophagus or gastroesophageal junction who underwent robotic-assisted transhiatal esophagectomy (RATE) without any surgical pyloric drainage. Patients with and without intraoperative endoscopic injection of 200 units of botulinum toxin in 10 cc of saline (BOTOX group) were compared to those that did not receive any pyloric drainage (noBOTOX group). Main outcome measure was the incidence of postoperative pyloric stenosis; secondary outcomes included operative and oncologic parameters, length of stay (LOS), morbidity, and mortality.

RESULTS

From November 2006 to August 2014, 41 patients (6 females) with a mean age of 65 years underwent RATE without surgical drainage of the pylorus. There were 14 patients in the BOTOX group and 27 patients in the noBOTOX group. Mean operative time was not different between the comparison groups. There was one conversion to open surgery in the BOTOX group. No pyloric dysfunction occurred in the BOTOX group postoperatively, and eight stenoses in the noBOTOX group (30%) required endoscopic therapy (P < .05). There were no differences in incidence of anastomotic strictures or anastomotic leaks. One patient in group noBOTOX required pyloroplasty 3 months after esophagectomy. There was one death in the noBOTOX group postoperatively (30-day mortality 2.4%). Mean LOS was 9.6 days, and BOTOX patients were discharged earlier (7.4 versus 10.7, P < .05).

CONCLUSION

Intraoperative endoscopic injection of botulinum toxin into the pylorus during RATE is feasible, safe, and effective and can prevent the need for pyloromyotomy.

Robotic versus laparoscopic gastrectomy for gastric cancer: comparison of short-term surgical outcomes

BACKGROUND

Robot-assisted gastrectomy (RAG) is a new minimally invasive surgical technique for gastric cancer. This study was designed to compare RAG with laparoscopy-assisted gastrectomy (LAG) in short-term surgical outcomes.

METHODS

Between October 2011 and August 2014, 423 patients underwent robotic or laparoscopic gastrectomy for gastric cancer: 93 RAG and 330 LAG. We performed a comparative analysis between RAG group and LAG group for clinicopathological characteristics and short-term surgical outcomes.

RESULTS

RAG was associated with a longer operative time (P < 0.001), lower blood loss (P = 0.001), and more harvested lymph nodes (P = 0.047). Only three patients in LAG group had positive margins, and R0 resection rate for RAG and LAG was similar (P = 0.823). The RAG group had postoperative complications of 9.8 %, comparable with those of the LAG group (P = 0.927). Proximal margin, distal margin, hospital stay, days of first flatus, and days of eating liquid diet for RAG and LAG were similar. In the subgroup of serosa-negative patients, RAG had a longer operation time (P = 0.003), less intraoperative blood loss (P = 0.005), and more harvested lymph nodes (P = 0.04). However, in the subgroup of serosa-positive patients, RAG had a longer operation time (P = 0.001), but no less intraoperative blood loss (P = 0.139) and no more harvested lymph nodes (P = 0.139). Similarly, in the subgroup of total gastrectomy patients, RAG had a longer operation time (P = 0.018), but no less intraoperative blood loss (P = 0.173).

CONCLUSIONS

The comparative study demonstrates that RAG is as acceptable as LAG in terms of surgical and oncologic outcomes. With lower estimated blood loss, acceptable complications, and radical resection, RAG is a promising approach for the treatment of gastric cancer. However, the indication of patients for RAG is critical.

Robotic surgery for gastric cancer

Laparoscopic gastrectomy is a widely used minimally invasive surgery for gastric cancer. However, skillful techniques are required to perform lymph node dissection using straight shaped forceps, particularly for D2 dissection. Robotic surgery using the da Vinci surgical system is anticipated to be a powerful tool for performing difficult techniques using high-resolution three-dimensional (3D) images and the EndoWrist equipped with seven degrees of freedom. Attempts are being made to apply robotic surgery in gastrectomy procedures mainly in Japan, South Korea, and Europe. Although definite superiority to laparoscopic gastrectomy is yet to be proven, robotic surgery has been reported to have a shorter learning curve and offer more precise dissection for total gastrectomy. Hence, its oncological efficacy needs to be verified in a clinical trial.

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

A meta-analysis of robotic versus laparoscopic gastrectomy for gastric cancer

BACKGROUND

Robot-assisted gastrectomy (RAG) for gastric cancer is still a controversial surgical technique for adequate tumor resection, lymphadenectomy, and postoperative outcome.

METHODS

A meta-analysis analyzed updated clinical trials that have compared RAG with laparoscopy-assisted gastrectomy (LAG) to evaluate whether RAG is equivalent to LAG.

RESULTS

Eight studies were included in the analysis, comprising 1,875 patients. RAG was associated with a longer operative time (p < 0.05), lower estimated blood loss (p < 0.05), and a longer distal margin (p < 0.05). RAG can be performed safely with lower estimated blood loss and a longer distal margin than with LAG. Complications, hospital stay, proximal margin, and harvested lymph nodes for RAG and LAG were similar.

CONCLUSIONS

RAG is as acceptable as LAG for obtaining safe complications and for performing radical gastrectomy.

Robot-assisted gastrectomy and oesophagectomy for cancer

BACKGROUND

Robot-assisted surgery is a technically feasible alternative to open and laparoscopic surgery, which is being more frequently used in general surgery. We undertook this review to investigate whether robotic assistance provides a significant benefit for oesophagogastric cancer surgery.

METHODS

Electronic databases were searched for original English-language publications for robotic-assisted gastrectomy and oesophagectomy between January 1990 and October 2013.

RESULTS

Sixty-one publications were included. Thirty-five included gastrectomy, 31 included oesophagectomy and five included both operations. Several publications suggest that robot-assisted subtotal gastrectomy can be as safe and effective as an open or laparoscopic procedure, with equal outcomes with regard to the number of lymph nodes resected, overall morbidity and perioperative mortality, and length of hospital stay. Robotic assistance is associated with longer operation times but also with less blood loss in some reports. A significant benefit for robotic assistance has not been shown for the more extensive operations of oesophagectomy or total gastrectomy with D2-lymphadenectomy. There are very few oncologic data regarding local recurrence or long-term survival for any of the robotic operations.

CONCLUSIONS

No significant differences in morbidity, mortality or number of lymph node harvested have been shown between robot-assisted and laparoscopic gastrectomy or oesophagectomy. Robotic surgery, with its relatively short learning curve, may facilitate reproducible minimally invasive surgery in this field but operation times are reportedly longer and cost differences remain unclear. Randomized trials with oncologic outcomes and cost comparisons are needed.

Robot-assisted laparoscopic (RAL) surgery for gastric cancer

BACKGROUND

This literature review focuses on the potential benefits and eventual limitations of robotic surgery with respect to the traditional minimally invasive laparoscopic surgical technique for gastric cancer.

METHODS

A literature survey was performed using specific search phrases in PubMed. Series including < 10 cases and series including only an 'open group' of patients in comparison with the 'robotic group' were excluded. Characteristics such as patient demographics, perioperative outcomes and oncological results were analysed.

RESULTS

According to the analysis of 12 series, robotic gastric surgery has been shown to be a safe and feasible method. However, a considerable number of studies are composed of early-stage gastric cancer cases and there seems to be a lack of randomized controlled studies.

CONCLUSIONS

Large prospective randomized studies are still required in order to demonstrate the exact benefits of robotic surgery and its effects on survival in gastric cancer.

Robot assistance in liver surgery: a real advantage over a fully laparoscopic approach? Results of a comparative bi-institutional analysis

BACKGROUND

Laparoscopic liver resection (LAPR) is safe and feasible with a better postoperative course as compared to open resections. Robot-assisted liver surgery (ROBR) is a potential alternative to LAPR. In this study we compare outcomes between ROBR and LAPR.

METHODS

Forty patients underwent ROBR and 223 LAPR for various indications. The surgical outcomes of two institutions, each with a specific advanced experience in laparoscopic and robotic surgery, were reviewed.

RESULTS

The major hepatectomy rate was significantly higher in LAPR (16.6% vs 0%, p = 0.011) while a parenchyma-preserving approach was favoured in ROBR (55% vs 34.1%, p = 0.019). More nodules were resected in the ROBR group (1.97 ± 1.4 vs 1.57 ± 1.1, p = 0.04). Overall conversion rate was 8/40 (20%) in the ROBR and 17/223 (7.6%) in the LAPR group (p = 0.034). Mean blood loss was 330 ± 303 ml and 174 ± 133 ml for the ROBR and LAPR groups, respectively (p = 0.001) CONCLUSIONS: Despite higher conversion rates and blood loss, robot-assisted surgery may allow the resection of more liver lesions, especially those located in the postero-superior segments, facilitating parenchyma-saving surgery with a comparable complication rate with respect to LAPR.

Combined thoracoscopic and laparoscopic robotic-assisted minimally invasive esophagectomy using a four-arm platform: experience, technique and cautions during early procedure development

OBJECTIVES

This study reports an early, single-institution experience of combined thoracoscopic and laparoscopic robotic-assisted minimally invasive esophagectomy (RAMIE) using a four-arm robotic platform, with special attention given to the pitfalls and complications during procedure development.

METHODS

We conducted a prospective, single-cohort, observational study of patients undergoing RAMIE at a single institution.

RESULTS

A total of 21 patients (median age, 62 years [range, 37-83 years]) underwent RAMIE with a four-arm robotic platform (17 by Ivor Lewis and 4 by McKeown). Of the patients, 17 (81%) had a complete (R0) resection, and 16 (76%) received induction treatment, the majority (14/21 [67%]) with combined chemoradiation. The median operative time was 556 min (range, 395-807 min), which decreased to 414 min (range, 405-543 min) for the last 5 cases in the series. The median estimated blood loss was 307 cm(3) (range, 200-500 cm(3)), and the median length of hospital stay was 10 days (range, 7-70 days). The median number of lymph nodes resected was 20 (range, 10-49). Five (24%) patients were converted to open procedures. Five patients (24%) had major complications. One (5%) died of complications on postoperative Day 70, and 3 (14%) had clinically significant anastomotic leaks (Grade II or greater, by Common Terminology Criteria for Adverse Events version 3.0). Three patients (14%) in this early experience developed airway fistulas.

CONCLUSIONS

While four-arm RAMIE may offer advantages over standard minimally invasive esophagectomy approaches, its adoption in a structured program, with critical evaluation of adverse events and subsequent adjustment of technique, is paramount to maximize patient safety, minimize complications and improve the conduct of operation early in the learning curve. Particular technical consideration should be given to prevention of airway complications.

Laparoscopic transhiatal resection for Siewert type II adenocarcinoma of the esophagogastric junction: operative technique and initial results

Laparoscopic distal gastrectomy has gained wide acceptance, and laparoscopic total gastrectomy (LTG) and laparoscopic proximal gastrectomy (LPG) are now also performed for gastric cancer. We extended these techniques to treat Siewert type II adenocarcinoma of the esophagogastric junction (AEG). Ten patients with clinical T1 AEG type II underwent laparoscopic transhiatal (LTH) resection combined with LTG reconstructed by Roux-en-Y (LTH+LTG: n=2) or LPG reconstructed by jejunal interposition (LTH+LPG: n=8). Intracorporeal esophagojejunostomy was performed using a circular stapler, of which the anvil head was introduced transabdominally or transorally. The median operation time was 243 minutes, and blood loss was 25.5 g. There were no intraoperative complications or conversion to open surgery. No anastomotic leak was observed, but 1 diaphragmatic herniation to the left thoracic cavity occurred postoperatively. The median length of the proximal margin was 14.5 mm. This operation is technically feasible and can be safely performed after adequate experience of LTG or LPG, though esophagojejunostomy in the mediastinum is technically demanding.