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Du X, Shen L, Xu S, Xu W, Yang J, Liu Y, Li K, Fan R, Yan L. Primary Robotic Versus Conventional Laparoscopic Roux-en-Y Gastric Bypass in Morbidly Obese Patients: A Systematic Review and Meta-Analysis. Surg Laparosc Endosc Percutan Tech 2024; 34:383-393. [PMID: 38828970 DOI: 10.1097/sle.0000000000001293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/29/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Robotic Roux-en-Y gastric bypass (RRYGB) and conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) are commonly performed as primary bariatric procedures. The aim of this article was to assess the role of RRYGB in patients undergoing primary bariatric procedures. METHODS All of the qualified studies were selected from the PubMed, Embase, and Web of Science databases, etc. We mainly compared the outcomes and safety between RRYGB and LRYGB. The outcomes evaluation included surgical effect and surgical safety. RESULT In total, 35 studies containing 426,463 patients were selected. The mortalities of patients adopting these 2 bariatric procedures were similar (RRYGB: 59/28,023, 0.21%; LRYGB: 612/397,945, 0.15%). We found no significant difference between RRYGB and LRYGB in the incidence of postoperative complications (30-day: OR=1.06, P =0.18; 1-y: OR=1.06, P =0.92). The incidence of 30-day readmission after the operation was higher in RRYGB patients (OR=1.24, P =0.003). However, we found that the RRYGB group had a lower incidence of anastomotic stricture 1 year after the operation when compared with LRYGB (OR=0.35, P =0.0004). The 1-year %EBMIL of these 2 groups was similar (78.53% vs. 76.02%). There was no significant difference in length of hospital stay (LOS) (WMD=-0.03d, P =0.59), conversion rate (OR=0.84, P =0.75), or anastomotic leak (OR=1.00, P =0.99) between these 2 groups. The mean hospital charges were higher in the RRYGB group ($11234.75 vs. $9468.58). CONCLUSION This systematic review and meta-analysis showed no significant advantage of RRYGB in surgical effect or reduction of intraoperative complications. RRYGB may reduce the incidence of some postoperative long-term complications. The mean hospital charges of RRYGB were higher.
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Affiliation(s)
- Xiaoyu Du
- Department of General Surgery, the 940th Hospital of Joint Logistics Support Force of People's Liberation Army
- Northwest Minzu University
| | - Liwen Shen
- Department of Medical Information Data, the 940th Hospital of Joint Logistics Support Force of People's Liberation Army, Lanzhou, Gansu, China
| | - Shumei Xu
- Department of General Surgery, the 940th Hospital of Joint Logistics Support Force of People's Liberation Army
| | - Wei Xu
- Department of General Surgery, the 940th Hospital of Joint Logistics Support Force of People's Liberation Army
| | - Jiaxing Yang
- Department of General Surgery, the 940th Hospital of Joint Logistics Support Force of People's Liberation Army
| | - Yichen Liu
- Department of General Surgery, the 940th Hospital of Joint Logistics Support Force of People's Liberation Army
| | - Kun Li
- Department of General Surgery, the 940th Hospital of Joint Logistics Support Force of People's Liberation Army
| | - Ruifang Fan
- Department of General Surgery, the 940th Hospital of Joint Logistics Support Force of People's Liberation Army
| | - Long Yan
- Department of General Surgery, the 940th Hospital of Joint Logistics Support Force of People's Liberation Army
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Huttman MM, Smith AN, Robertson HF, Purves R, Biggs SE, Dewi F, Dixon LK, Kirkham EN, Jones CS, Ramirez J, Scroggie DL, Pathak S, Blencowe NS. A Systematic Review to Summarise and Appraise the Reporting of Surgical Innovation: a Case Study in Robotic Roux-en-Y Gastric Bypass. Obes Surg 2024; 34:3058-3070. [PMID: 38898310 PMCID: PMC11289006 DOI: 10.1007/s11695-024-07329-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 05/27/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024]
Abstract
Robotic Roux-en-Y gastric bypass (RRYGB) is an innovative alternative to traditional laparoscopic approaches. Literature has been published investigating its safety/efficacy; however, the quality of reporting is uncertain. This systematic review used the Idea, Development, Exploration, Assessment and Long-term follow-up (IDEAL) framework to assess the reporting quality of available literature. A narrative summary was formulated, assessing how comprehensively governance/ethics, patient selection, demographics, surgeon expertise/training, technique description and outcomes were reported. Forty-seven studies published between 2005 and 2024 were included. There was incomplete/inconsistent reporting of governance/ethics, patient selection, surgeon expertise/training and technique description, with heterogenous outcome reporting. RRYGB reporting was poor and did not align with IDEAL guidance. Robust prospective studies reporting findings using IDEAL/other guidance are required to facilitate safe widespread adoption of RRYGB and other surgical innovations.
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Affiliation(s)
- Marc M Huttman
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road BS8 2PS, Bristol, BS81QU, UK
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, NW12PB, UK
| | - Alexander N Smith
- Peterborough City Hospital, Northwest Anglia NHS Foundation Trust, Peterborough, PE39GZ, UK
| | - Harry F Robertson
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road BS8 2PS, Bristol, BS81QU, UK
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, W21NY, UK
| | - Rory Purves
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road BS8 2PS, Bristol, BS81QU, UK
- Southport and Ormskirk Hospitals NHS Trust, Southport, PR86PN, UK
| | - Sarah E Biggs
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road BS8 2PS, Bristol, BS81QU, UK
| | - Ffion Dewi
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road BS8 2PS, Bristol, BS81QU, UK
| | - Lauren K Dixon
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road BS8 2PS, Bristol, BS81QU, UK
| | - Emily N Kirkham
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road BS8 2PS, Bristol, BS81QU, UK
| | - Conor S Jones
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road BS8 2PS, Bristol, BS81QU, UK
| | - Jozel Ramirez
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road BS8 2PS, Bristol, BS81QU, UK
| | - Darren L Scroggie
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road BS8 2PS, Bristol, BS81QU, UK
- Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, BS28HW, UK
| | - Samir Pathak
- St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS97TF, UK
| | - Natalie S Blencowe
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road BS8 2PS, Bristol, BS81QU, UK.
- St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS97TF, UK.
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Saleh T, Ford J, Kindel T, Higgins R, Lak K, Gould J, Tan WH. Inpatient opioid use and pain control after robotic versus laparoscopic sleeve gastrectomy. Surgery 2024; 175:599-604. [PMID: 37981549 DOI: 10.1016/j.surg.2023.08.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/19/2023] [Accepted: 08/08/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND During the past decade, the proportion of bariatric surgery performed robotically has been rising. However, the clinical benefits of the robotic approach over laparoscopy are uncertain. One area in need of further investigation is pain control after robotic versus laparoscopic bariatric surgery. METHODS A retrospective cohort study was conducted of bariatric surgery patients undergoing laparoscopic or robotic sleeve gastrectomy at a single institution from October 2019 to August 2022. Inpatient opioid use was measured in morphine milliequivalents. Pain scores were collected by the nursing staff. RESULTS A total of 368 patients were included: 286 laparoscopic and 82 robotic surgery patients. The groups shared similar demographics. For the entire cohort, the mean age was 42 years, the body mass index was 50 kg/m2, and 79% were female. Mean operative time was significantly lower for laparoscopic surgeries (87.5 ± 47.3 minutes vs 109.3 ± 30.3 minutes; P < .01). The median total inpatient morphine milligram equivalents used was similar for both groups: 52.3 (31.5-77.0) for the laparoscopic group versus 40 (24-74.5) for robotic (P = .13). Mean postoperative pain scores (scale out of 10) were not significantly different between groups: 5.2 ± 1.7 (postoperative day 0) and 4.5 ± 1.7 (day 1) for laparoscopic patients versus 5.1 ± 2.0 (day 0) and 4.4 ± 1.8 (day 1) for robotic. The proportion of patients prescribed opioids at discharge was significantly higher for the laparoscopic group (75.2% vs 62.2%; P = .02). Other clinical outcomes, including duration of stay, 30-day readmissions, and visits to the emergency department, were not significantly different. CONCLUSION There is no difference in inpatient opioid use or pain scores between patients undergoing laparoscopic and robotic sleeve gastrectomy.
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Affiliation(s)
- Tariq Saleh
- Medical College of Wisconsin Department of Surgery, Division of Minimally Invasive and Gastrointestinal Surgery
| | - Jordanne Ford
- Medical College of Wisconsin Department of Surgery, Division of Minimally Invasive and Gastrointestinal Surgery
| | - Tammy Kindel
- Medical College of Wisconsin Department of Surgery, Division of Minimally Invasive and Gastrointestinal Surgery
| | - Rana Higgins
- Medical College of Wisconsin Department of Surgery, Division of Minimally Invasive and Gastrointestinal Surgery. https://twitter.com/RMHigginsMD
| | - Kathleen Lak
- Medical College of Wisconsin Department of Surgery, Division of Minimally Invasive and Gastrointestinal Surgery
| | - Jon Gould
- Medical College of Wisconsin Department of Surgery, Division of Minimally Invasive and Gastrointestinal Surgery. https://twitter.com/joncgould
| | - Wen Hui Tan
- Medical College of Wisconsin Department of Surgery, Division of Minimally Invasive and Gastrointestinal Surgery.
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Leang YJ, Mayavel N, Yang WTW, Kong JCH, Hensman C, Burton PR, Brown WA. Robotic versus laparoscopic gastric bypass in bariatric surgery: a systematic review and meta-analysis on perioperative outcomes. Surg Obes Relat Dis 2024; 20:62-71. [PMID: 37730445 DOI: 10.1016/j.soard.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/22/2023] [Accepted: 08/05/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Robotic-assisted surgery has emerged as a compelling approach to bariatric surgery. However, current literature has not consistently demonstrated superior outcomes to laparoscopic bariatric surgery to justify its higher cost. With its mechanical advantages, the potential gains from the robotic surgical platform are likely to be apparent in more complex cases such as gastric bypass, especially revisional cases. OBJECTIVE This systematic review and meta-analysis aimed to summarize the literature and evaluate the peri-operative outcomes of patients with obesity undergoing robotic gastric bypass versus laparoscopic gastric bypass surgery. SETTING Systematic review. METHODS A literature search of Embase, Medline, Pubmed, Cochrane library, and Google Scholar was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing outcomes of robotic and laparoscopic gastric bypass for obesity were included. RESULTS Twenty-eight eligible studies comprised a total of 82,155 patients; 9051 robotic bypass surgery (RBS) versus 73,104 laparoscopic bypass surgery (LBS) were included. All included studies compared Roux-en-Y gastric bypass. RBS was noted to have higher reoperation rate within 30 days (4.4% versus 3.4%; odds ratio 1.31 [95% CI, 1.04-1.66]; P = .027; I2 = 43.5%) than LBS. All other endpoints measured (complication rate, anastomotic leak, anastomotic stricture, surgical site infections, hospital readmission, length of stay, operative time, conversion rate and mortality) did not show any difference between RBS and LBS. CONCLUSION This systematic review and meta-analysis showed that there was no significant difference in key outcome measures in robotic versus laparoscopic gastric bypass. RBS was associated with a slightly higher reoperation rate and there was no reduction in overall complication rate with the use of robotic platform.
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Affiliation(s)
- Yit J Leang
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia; Oesophago-gastric and Bariatric Unit, Department of General Surgery, The Alfred Hospital, Melbourne, Australia.
| | - Naveen Mayavel
- Oesophago-gastric and Bariatric Unit, Department of General Surgery, The Alfred Hospital, Melbourne, Australia
| | - Wilson T W Yang
- Oesophago-gastric and Bariatric Unit, Department of General Surgery, The Alfred Hospital, Melbourne, Australia
| | - Joseph C H Kong
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia
| | - Chrys Hensman
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia
| | - Paul R Burton
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia; Oesophago-gastric and Bariatric Unit, Department of General Surgery, The Alfred Hospital, Melbourne, Australia
| | - Wendy A Brown
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia; Oesophago-gastric and Bariatric Unit, Department of General Surgery, The Alfred Hospital, Melbourne, Australia
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5
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Rampp N, Sudan R. Robotic Bariatric Surgery: An Update. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00353-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
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Griffin KL, Ragan MV, Patterson KN, Diefenbach KA, Needleman BJ, Aldrink JH, Michalsky MP. Robotic-Assisted Metabolic and Bariatric Surgery in the Pediatric Population. Semin Pediatr Surg 2023; 32:151257. [PMID: 36739691 DOI: 10.1016/j.sempedsurg.2023.151257] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Kristine L Griffin
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Mecklin V Ragan
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kelli N Patterson
- Department of Surgery, The Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Karen A Diefenbach
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Bradley J Needleman
- Department of Surgery, The Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Jennifer H Aldrink
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Marc P Michalsky
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
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7
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Cost-Effectiveness of Totally Robotic and Conventional Laparoscopic Roux-en-Y Gastric Bypass: A Systematic Review and Meta-Analysis. Bariatr Surg Pract Patient Care 2022. [DOI: 10.1089/bari.2022.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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8
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Iranmanesh P, Shah SK, Chevallay M, Toso C, Mönig SP, Hagen ME, Wilson EB, Jung MK. Assessment of predictors of early postoperative complications after primary robotically assisted Roux-en-Y gastric bypass: a multicenter, retrospective cohort study. Surg Endosc 2022; 37:2851-2857. [PMID: 36484858 PMCID: PMC10082102 DOI: 10.1007/s00464-022-09766-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 11/06/2022] [Indexed: 12/14/2022]
Abstract
Abstract
Background
Robotic Roux-en-Y gastric bypass (RRYGB) is performed in an increasing number of bariatric centers worldwide. Previous studies have identified a number of demographic and clinical variables as predictors of postoperative complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Some authors have suggested better early postoperative outcomes after RRYGB compared to LRYGB. The objective of the present study was to assess potential predictors of early postoperative complications after RRYGB.
Methods
A retrospective analysis of two prospective databases containing patients who underwent RRYGB between 2006 and 2019 at two high volumes, accredited bariatric centers was performed. Primary outcome was rate of 30 day postoperative complications. Relevant demographic, clinical and biological variables were entered in a multivariate, logistic regression analysis to identify potential predictors.
Results
Data of 1276 patients were analyzed, including 958 female and 318 male patients. Rates of overall and severe 30 day complications were 12.5% (160/1276) and 3.9% (50/1276), respectively. Rate of 30 day reoperations was 1.6% (21/1276). The overall gastrointestinal leak rate was 0.2% (3/1276). Among various demographic, clinical and biological variables, male sex and ASA score >2 were significantly correlated with an increased risk of 30 day complication rates on multivariate analysis (OR 1.68 and 1.67, p=0.005 and 0.005, respectively).
Conclusion
This study identified male sex and ASA score >2 as independent predictors of early postoperative complications after RRYGB. These data suggest a potentially different risk profile in terms of early postoperative complications after RRYGB compared to LYRGB. The robotic approach might have a benefit for patients traditionally considered to be at higher risk of complications after LRYGB, such as those with BMI >50. The present study was however not designed to assess this hypothesis and larger, prospective studies are necessary to confirm these results.
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Affiliation(s)
- Pouya Iranmanesh
- Division of Digestive Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Shinil K Shah
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mickael Chevallay
- Division of Digestive Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Stefan P Mönig
- Division of Digestive Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Monika E Hagen
- Division of Digestive Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Erik B Wilson
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Minoa K Jung
- Division of Digestive Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland.
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Fantola G, Moroni E, Runfola M, Lai E, Pintus S, Gallucci P, Pennestrì F, Raffaelli M. Controversial Role of Robot in Primary and Revisional Bariatric Surgery Procedures: Review of the Literature and Personal Experience. Front Surg 2022; 9:916652. [PMID: 35711697 PMCID: PMC9194091 DOI: 10.3389/fsurg.2022.916652] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/02/2022] [Indexed: 11/25/2022] Open
Abstract
Laparoscopy is the surgical standard of care for bariatric procedures; however, during the last two decades, the robotic approach has gained increasing interest. It is currently considered a safe and effective alternative to laparoscopy. This literature review investigates the role of the robotic approach for primary and revisional bariatric procedures, with the particular aim of comparing this technique with the standard-of-care laparoscopic approach. The feasibility of robotic dissection and suturing could have potential advantages: robotics may prevent the risk of leak and bleeding and other surgical complications, determining potential benefits in terms of operative time, length of hospital stay, and learning curve. Considering primary procedures, the literature reveals no advantages in robotic versus the laparoscopic approach for adjustable gastric banding and sleeve gastrectomy. Robotic Roux-en-Y gastric bypass is associated with a longer operative time and a shorter hospital length of stay than laparoscopy. The robotic approach in revisional surgery has been proven to be safe and effective. Despite the longer operative time, the robotic platform could achieve a lower bleeding rate compared with laparoscopy. The surgeon’s selection criteria related to referrals to the robotic approach of difficult-perceived cases could represent a bias. In conclusion, robotic surgery can be considered a safe and effective approach in both primary and revisional bariatric surgery, despite the lack of evidence to support its routine use in primary bariatric surgery. However, in revisional bariatric surgery and in surgical complex procedures, the robotic approach could have potential benefits in terms of surgical complications and learning curves.
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Affiliation(s)
- Giovanni Fantola
- Obesity Surgery Unit, Department of Surgery, ARNAS G. Brotzu, Cagliari, Italy
- Correspondence: Giovanni Fantola
| | - Enrico Moroni
- Obesity Surgery Unit, Department of Surgery, ARNAS G. Brotzu, Cagliari, Italy
| | - Matteo Runfola
- Emergency Surgery Unit, Department of Surgery, ARNAS G. Brotzu, Cagliari, Italy
| | - Emanuele Lai
- Obesity Surgery Unit, Department of Surgery, ARNAS G. Brotzu, Cagliari, Italy
| | - Stefano Pintus
- Obesity Surgery Unit, Department of Surgery, ARNAS G. Brotzu, Cagliari, Italy
| | - Pierpaolo Gallucci
- Division of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Pennestrì
- Division of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Raffaelli
- Division of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Robotic vs. Laparoscopic Metabolic and Bariatric Surgery, Outcomes over 5 Years in Nearly 800,000 Patients. Obes Surg 2022; 32:2341-2348. [DOI: 10.1007/s11695-022-06082-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/14/2022] [Accepted: 04/20/2022] [Indexed: 12/25/2022]
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Zhang Z, Miao L, Ren Z, Li Y. Robotic bariatric surgery for the obesity: a systematic review and meta-analysis. Surg Endosc 2021; 35:2440-2456. [PMID: 33881624 DOI: 10.1007/s00464-020-08283-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/31/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The aim of this meta-analysis is to evaluate the safety and efficacy of bariatric surgery (BS) in patients with obesity by robotic bariatric surgery (RBS) compared with laparoscopic bariatric surgery (LBS). METHODS The study was performed through searching in Pubmed, Web of Science, Embase database and Cochrane Library until March 31, 2020 comparing RBS with LBS. Data were calculated on the following endpoints: operative time, length of hospital stay, reoperation within 30 days, overall complications, leak, stricture, pulmonary embolisms, estimated blood loss and mortality. Data as relative risks (OR), or weighted mean difference (WMD) were summarized with 95% confidence interval (CI). Risk of publication bias was assessed through standard methods. RESULTS Thirty eligible trials including 7,239 robotic and 203,181 laparoscopic surgery cases showed that RBS was referred to attain longer operative time [WMD = 27.61 min; 95%CI (16.27-38.96); P < 0.01] and lower mortality [OR 2.40; 95% CI (1.24-4.64); P = 0.009] than LBS. Length of hospital stay [WMD = - 0.02; 95% CI (- 0.19-0.15); P = 0.819], reoperation within 30 days [OR 1.36; 95% CI (0.65-2.82); P = 0.411], overall complications [OR 0.88; 95% CI (0.68-1.15); P = 0.362], leak [OR 1.04; 95% CI (0.43-2.51); P = 0.933], stricture [OR 1.05; 95% CI (0.52-2.12); P = 0.895], pulmonary embolisms [OR 1.97; 95% CI (0.93-4.17); P = 0.075], estimated blood loss[WMD = - 1.93; 95% CI (- 4.61-0.75); P = 0.158] were almost similar in both RBS group and LBS group. Three was no statistically significant difference between RRYGB and LRYGB in EWL%, no statistical significance between RSG and LSG after 1 year, 2 years and 3 years. CONCLUSION RBS presented lower mortality within 90 days and longer operative time in this meta-analysis with similar safety and efficacy for the obesity compared with LBS in other outcomes. Additionally, RBS might be beneficial in the future if it would be evaluated in comprehensive and long-term endpoints.
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Affiliation(s)
- Zhengchao Zhang
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, 730000, China
- Key Laboratory of Digestive System Tumors of Gansu Province, Lanzhou, 730000, China
| | - Lele Miao
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, 730000, China
- Key Laboratory of Digestive System Tumors of Gansu Province, Lanzhou, 730000, China
| | - Zhijian Ren
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, 730000, China
- Key Laboratory of Digestive System Tumors of Gansu Province, Lanzhou, 730000, China
| | - Yumin Li
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, 730000, China.
- Key Laboratory of Digestive System Tumors of Gansu Province, Lanzhou, 730000, China.
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12
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The Longitudinal Efficiency of Robotic Surgery: an MBSAQIP Propensity Matched 4-Year Comparison of Robotic and Laparoscopic Bariatric Surgery. Obes Surg 2021; 30:3706-3713. [PMID: 32495073 DOI: 10.1007/s11695-020-04712-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The objective of this study was to examine the MBSAQIP database to assess efficiency trends and perioperative outcomes in robotic bariatric surgery. METHODS Robotic (RA) and laparoscopic (L) sleeve gastrectomy (SG) and gastric bypass (RYGB) were compared using the 2015-2018 MBSAQIP Participant Use Data Files. Patients were propensity matched 1:1 based on sex, body mass index, assistant, and previous obesity or foregut surgery. A total of 93,802 patients were included. RESULTS Median operative times were significantly longer for both RA-SG (89 vs. 62 min; p < 0.0001) and RA-RYGB (141 vs. 105 min; p < 0.0001) compared with laparoscopic. Over the 4-year period, the difference in operative times (OR delta) between RA-SG and L-SG was unchanged while the difference in operative times between RA-RYGB and L-RYGB increased. Both robotic groups were significantly more likely to be readmitted (RA-SG p = 0.001, RA-RYGB p = 0.006). Robotic SG was more likely to have a reintervention (p = 0.018) and extended length of stay (LOS) (> 4 days) compared with laparoscopic (p = < 0.0002). No significant differences were noted in morbidity and mortality by approach. CONCLUSIONS Operative times were 30% longer for RA-SG and 25% longer for RA-RYGB when compared with laparoscopic. There was no significant improvement in OR delta for either RA-SG or RA-RYGB over the four years. Readmission rates were higher for both RA-SG and RA-RYGB. Robotic SG had a greater percentage of patients with extended LOS compared with laparoscopic. No evidence of improved efficiency for robotic bariatric surgery as defined by operative time or clinical outcomes was identified.
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Robotic Roux en Y gastric bypass can be safe and cost-effective in a rural setting: clinical outcomes from a community hospital bariatric program. J Robot Surg 2021; 15:929-936. [PMID: 33507471 DOI: 10.1007/s11701-021-01193-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 01/15/2021] [Indexed: 10/22/2022]
Abstract
Robotic Roux en Y gastric bypass (R-RYGB) is becoming more common due to the shifting trend toward robotic gastrointestinal surgery. The goal of this study is to determine if R-RYGB can be safely implemented at a robotic bariatric surgery program in a community hospital with similar results to laparoscopic RYGB (L-RYGB) in a cost-effective manner. A total of 50 R-RYGB procedures were performed with the Xi and the X da Vinci systems and compared with 50 L-RYGB cases by a single surgeon from October 2018 to January 2020 at an acute-care community hospital in a rural setting with a high-volume MBSAQIP-accredited program. A retrospective chart review was conducted with IRB approval and statistical analysis of 30-day morbidity, mortality, re-interventions, and resolution of co-morbidities, with financial analysis of cost reduction. Both groups were similar in age, gender, ASA class, co-morbidities, and body mass index (BMI). There was no mortality or anastomotic leak. The 30-day morbidity for R-RYGB was 10.0% with a re-operation rate of 4.0%. There were no conversions to open, and the mean hospital length of stay was 2.22 ± 1.19 days. There were no statistically significant differences between R-RYGB and L-RYGB with respect to any measured outcome, including intraoperative time (121.94 vs. 113.52, respectively; p = 0.1495). However, when incidences and percentages were used, R-RYGB had improved performance for most of the outcomes measuring safety. There was an average cost reduction of $816.90 per case (total saving of $40,845.00 for 50 cases) in the R-RYGB by transitioning from a hybrid approach to a totally robotic approach. R-RYGB appears to be as safe as L-RYGB and can be performed in a rural community hospital while maintaining a low complication rate, achieving a high co-morbidity resolution rate, and saving costs with a totally robotic approach.
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14
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Lainas P, Kassir R, Benois M, Derienne J, Debs T, Safieddine M, Gugenheim J, Dagher I, Amor IB. Comparative analysis of robotic versus laparoscopic Roux-en-Y gastric bypass in severely obese patients. J Robot Surg 2021; 15:891-898. [PMID: 33484415 DOI: 10.1007/s11701-020-01181-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/17/2020] [Indexed: 01/08/2023]
Abstract
Benefits of robotic surgery for Roux-en-Y gastric bypass (RYGB) are still debated. We aimed to compare conventional laparoscopic (L-RYGB) to robotic RYGB (R-RYGB) and evaluate safety, efficacy, advantages and drawbacks of each procedure. A prospective cohort study with a retrospective review approach was conducted to analyze results of L-RYGB and R-RYGB performed at a bariatric center of excellence. Patient demographics, perioperative data, weight loss, comorbidities evolution and cost were assessed. One hundred and sixty-one severely obese patients underwent R-RYGB and L-RYGB, respectively. Patient's characteristics were similar between groups. Intraoperative blood loss was similar (p = 0.91), with no requirement for blood transfusion. Median operative time was significantly reduced for R-RYGB (127 vs 160 min; p < 0.001). Seven patients (11.4%) in the L-RYGB group and 15 patients (15%) in the R-RYGB group had early postoperative complications (p = 0.63), with more anastomotic leaks and stenosis for R-RYGB during initial learning curve (p = NS). Mortality was null. Median length of hospital stay was similar (6 days; p = 0.20). Mean hospital cost was non-significantly increased for R-RYGB ($5730 vs. $4879; p = 0.34). Two years after surgery, median BMI and mean EWL% were similar for both groups (26.1 vs 26.5 kg/m2 and 89.9% vs 90.9% for L-RYGB and R-RYGB groups, respectively; p = 0.71 and 0.85, respectively), with no statistically significant difference in comorbidities between the two groups (p = 0.80). R-RYGB is feasible and safe within the reach of every laparoscopic surgeon. In our series, it was associated with shorter operative time and equivalent length of stay and weight loss outcomes compared to L-RYGB. Further well-designed randomized studies are necessary to draw safe conclusions.
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Affiliation(s)
- Panagiotis Lainas
- Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, Assistance Publique-Hôpitaux de Paris, 157 rue de la Porte de Trivaux, 92141, Clamart cedex, France. .,Paris-Saclay University, 91405, Orsay, France.
| | - Radwan Kassir
- Department of Digestive and Bariatric Surgery, CHU Felix-Guyon, Saint-Denis, La Reunion, France
| | - Marine Benois
- Department of Digestive Surgery, Archet II Hospital, Nice, France.,University of Nice-Sophia-Antipolis, Nice, France
| | - Joseph Derienne
- Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, Assistance Publique-Hôpitaux de Paris, 157 rue de la Porte de Trivaux, 92141, Clamart cedex, France
| | - Tarek Debs
- Department of Digestive Surgery, Archet II Hospital, Nice, France.,University of Nice-Sophia-Antipolis, Nice, France
| | - Maissa Safieddine
- Methodological Support Unit, INSERM, CIC1410, CHU Felix-Guyon, Saint-Denis, La Reunion, France
| | - Jean Gugenheim
- Department of Digestive Surgery, Archet II Hospital, Nice, France.,University of Nice-Sophia-Antipolis, Nice, France
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, Assistance Publique-Hôpitaux de Paris, 157 rue de la Porte de Trivaux, 92141, Clamart cedex, France.,Paris-Saclay University, 91405, Orsay, France
| | - Imed Ben Amor
- Department of Digestive Surgery, Archet II Hospital, Nice, France.,University of Nice-Sophia-Antipolis, Nice, France
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Pastrana M, Stoltzfus J, AlMandini A, El Chaar M. Evolution of outcomes of robotic bariatric surgery: first report based on MBSAQIP database. Surg Obes Relat Dis 2020; 16:916-922. [PMID: 32340825 DOI: 10.1016/j.soard.2020.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 11/12/2019] [Accepted: 01/04/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Robotic surgery is increasingly being used in bariatric surgery; however, the benefits of robotic surgery in bariatrics remain controversial. OBJECTIVES The objective of this study was to compare the outcomes of robotic bariatric surgery with laparoscopic surgery over a 3-year period between 2015 and 2017 using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. SETTING University Hospital, United States. METHODS Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for the years 2015 to 2017, we included patients who underwent primary robotic or laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass procedures. Patients were divided into either robotic or laparoscopic groups. Primary outcomes included serious adverse events, organ space infection (OSI), readmissions, reoperations, and interventions at 30 days. Secondary outcomes included operation length and hospital stay. We performed propensity score matching based on clinically relevant preoperative variables to create balanced groups before analysis. We analyzed our data using separate Cochran-Mantel-Haenszel tests with year as the stratification variable and conducted subgroup analyses for robotic patients only using separate t tests for proportions, with P < .05 denoting statistical significance. RESULTS Of the 315,647 patients available for comparison in the 2015 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant User Files, there were 41,364 matched in the final data set. Using the Cochran-Mantel-Haenszel test, we found a significant association between year of performance and outcomes for OSI, 30 day-readmission, and intervention. The incidence of OSI after laparoscopic and robotic cases was .3% and .4%, respectively, in 2015 versus .2% and .3%, respectively, in 2017 (P = .04, odds ratio = 1.49). Thirty-day readmission for robotic cases was 5.2% in 2015 and 4.0% in 2017 (P < .05, odds ratio = 1.16). The incidence of 30-day intervention for robotic cases also dropped from 2.2% in 2015 to 1.3% in 2017 (P < .05, odds ratio = 1.37). Using a Student's t test, there was also a statistically significant decrease in serious adverse events in the robotic group between 2015 and 2017 (incidence of serious adverse events in 2015 was 5.2% versus 3.7% in 2017, P < .05). Rate of 30-day reoperation for the robotic group did change over time but was comparable to the laparoscopic group (1.4% versus 1.3%). CONCLUSIONS Our study showed between 2015 and 2017 the outcomes of robotic bariatric surgery have improved as evidenced by the significant decrease in the rate of OSI, readmissions, and interventions at 30 days.
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Affiliation(s)
- Marlon Pastrana
- St. Luke's University Hospital and Health Network (SLUHN), Bethlehem, Pennsylvania
| | - Jill Stoltzfus
- St. Luke's University Hospital and Health Network (SLUHN), Bethlehem, Pennsylvania
| | - Amin AlMandini
- St. Luke's University Hospital and Health Network (SLUHN), Bethlehem, Pennsylvania
| | - Maher El Chaar
- St. Luke's University Hospital and Health Network (SLUHN), Bethlehem, Pennsylvania.
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Veilleux E, Ponce J, Lutfi R. A Review of the Role of Robotics in Bariatric Surgery: Finding Our Future? J Laparoendosc Adv Surg Tech A 2020; 30:36-39. [DOI: 10.1089/lap.2019.0419] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Eric Veilleux
- Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Jaime Ponce
- Chattanooga Bariatrics, Chatanooga, Tennessee
| | - Rami Lutfi
- Advocate Illinois Masonic Medical Center, Chicago, Illinois
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Bustos R, Mangano A, Gheza F, Chen L, Aguiluz-Cornejo G, Gangemi A, Sanchez-Johnsen L, Hassan C, Masrur M. Robotic-Assisted Roux-en-Y Gastric Bypass: Learning Curve Assessment Using Cumulative Sum and Literature Review. Bariatr Surg Pract Patient Care 2019; 14:95-101. [PMID: 31572625 DOI: 10.1089/bari.2018.0042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Purpose: Robotic-assisted Roux-en-Y gastric bypass (RARYGB) is a procedure that is used with increasing frequency in the United States. Among other bariatric procedures, RARYGB is a good model for the robotic platform because it allows hand-sewn suturing and energy devices application. The aim of this study was to conduct a literature review of robotic approach in RARYGB, its learning curve using the cumulative sum (CUSUM) method, and our experience as Center of Excellence recognized by the American Society for Metabolic and Bariatric Surgery (ASMBS). Methods: A total of 67 patients were included. Results revealed that the learning curve was achieved after case 11. Eighteen studies were included in the pooled analysis. Results: An increase in the operative time was noted at case 46, in which a second phase was identified. A significant difference between these two phases was found only related to previous bariatric surgery. The outcomes of this series were comparable with the ones available in the literature. Conclusions: The robotic platform is increasing its role in complex procedures such as RARYGB. The hand-sewn technique may offer important advantages in terms of shorter learning curve, reduced conversion rate, and lower leakage rate.
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Affiliation(s)
- Roberto Bustos
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Alberto Mangano
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Federico Gheza
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Liaohai Chen
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Gabriela Aguiluz-Cornejo
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Antonio Gangemi
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Lisa Sanchez-Johnsen
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Chandra Hassan
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Mario Masrur
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
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18
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Acevedo E, Mazzei M, Zhao H, Lu X, Soans R, Edwards MA. Outcomes in conventional laparoscopic versus robotic-assisted primary bariatric surgery: a retrospective, case-controlled study of the MBSAQIP database. Surg Endosc 2019; 34:1353-1365. [PMID: 31209608 PMCID: PMC7222911 DOI: 10.1007/s00464-019-06915-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 06/12/2019] [Indexed: 12/16/2022]
Abstract
Introduction Robotic-assisted bariatric surgery is increasingly performed. There remains controversy about the overall benefit of robotic-assisted (RBS) compared to conventional laparoscopic (LBS) bariatric surgery. In this study, we used a large national risk-stratified bariatric clinical database to compare outcomes between robotic and laparoscopic gastric bypass (RNYGB) and sleeve gastrectomy (SG). Methods A retrospective analysis of the 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use Data File (PUF) was performed. Primary robotic and laparoscopic RYNGB and SG were analyzed. Descriptive analysis was performed of the unmatched cohorts, followed by 1:3 case-controlled matching. Cases and controls were matched by patient demographics and pre-operative comorbidities, and peri-operative outcomes compared. Results 77,991 Roux-en-Y gastric bypass (RnYGB) (7.5% robotic-assisted) and 189,503 SG (6.8% robotic-assisted) cases were identified. Operative length was significantly higher in both the robotic-assisted RnYGB and SG cohorts (p < 0.0001). Outcomes were similar between the robotic-assisted and laparoscopic RnYGB cohorts, except a lower mortality rate (p = 0.05), transfusion requirement (p = 0.005), aggregate bleeding (p = 0.04), and surgical site infections (SSI) (p = 0.006) in the robotic-assisted cohort. Outcomes were also similar between robotic-assisted and laparoscopic SG, except for a longer length of stay (p < 0.0001) and higher rates of conversion (p < 0.0001), 30-day intervention (p = 0.01), operative drain present (p < 0.0001), sepsis (p = 0.01), and organ space SSI (p = 0.0002) in the robotic cohort. Bleeding was lower in the robotic SG cohort and mortality was similar. Conclusion Both robotic-assisted and laparoscopic RnYGB and SG are overall very safe. Robotic-assisted gastric bypass is associated with a lower mortality and morbidity; however, a clear benefit for robotic-assisted SG compared to laparoscopic SG was not seen. Given the longer operative and hospital duration, robotic SG is not cost-effective. Electronic supplementary material The online version of this article (10.1007/s00464-019-06915-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Edwin Acevedo
- Department of Surgery, Division of Bariatric and Minimally Invasive Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Michael Mazzei
- Department of Surgery, Division of Bariatric and Minimally Invasive Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Huaqing Zhao
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Xiaoning Lu
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Rohit Soans
- Department of Surgery, Division of Bariatric and Minimally Invasive Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Michael A Edwards
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd. S, Jacksonville, FL, 32224, USA.
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19
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Acevedo E, Mazzei M, Zhao H, Lu X, Edwards MA. Outcomes in conventional laparoscopic versus robotic-assisted revisional bariatric surgery: a retrospective, case-controlled study of the MBSAQIP database. Surg Endosc 2019; 34:1573-1584. [PMID: 31209611 PMCID: PMC7223848 DOI: 10.1007/s00464-019-06917-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 06/12/2019] [Indexed: 12/18/2022]
Abstract
Introduction Revisional bariatric surgery is being increasingly performed and is associated with higher operative risks. Optimal techniques to minimize complications remain controversial. Here, we report a retrospective review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant User Files (PUF) database, comparing outcomes between revision RBS and LBS. Methods The 2015 and 2016 MBSAQIP PUF database was retrospectively reviewed. Revision cases were identified using the Revision/Conversion Flag. Selected cases were further stratified by surgical approach. Subgroup analysis of sleeve gastrectomy and gastric bypass cases was performed. Case–controlled matching (1:1) was performed of the RBS and LBS cohorts, including gastric bypass and sleeve gastrectomy cohorts separately. Cases and controls were match by demographics, ASA classification, and preoperative comorbidities. Results 26,404 revision cases were identified (93.3% LBS, 6.7% RBS). 85.6% were female and 67% white. Mean age and BMI were 48 years and 40.9 kg/m2. 1144 matched RBS and LBS cases were identified. RBS was associated with longer operative duration (p < 0.0001), LOS (p = 0.0002) and a higher rate of ICU admissions (1.3% vs 0.5%, p = 0.05). Aggregate bleeding and leak rates were higher in the RBS cohort. In both gastric bypass and sleeve gastrectomy cohorts, the robotic-assisted surgery remain associated with longer operative duration (p < 0.0001). In gastric bypass, rates of aggregate leak and bleeding were higher with robotic surgery, while transfusion was higher with laparoscopy. For sleeve gastrectomy cases, reoperation, readmission, intervention, sepsis, organ space SSI, and transfusion were higher with robotic surgery. Conclusion In this matched cohort analysis of revision bariatric surgery, both approaches were overall safe. RBS was associated with longer operative duration and higher rates of some complications. Complications were higher in the robotic sleeve cohort. Robotic is likely less cost-effective with no clear patient safety benefit, particularly for sleeve gastrectomy cases.
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Affiliation(s)
- Edwin Acevedo
- Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Michael Mazzei
- Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Huaqing Zhao
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Xiaoning Lu
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Michael A Edwards
- Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Temple University Hospital, Philadelphia, PA, USA. .,Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA.
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20
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Senellart P, Saint-Jalmes G, Mfam WS, Abou-Mrad A. Laparoscopic versus full robotic Roux-en-Y gastric bypass: retrospective, single-center study of the feasibility and short-term results. J Robot Surg 2019; 14:291-296. [DOI: 10.1007/s11701-019-00976-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 05/21/2019] [Indexed: 01/06/2023]
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Clapp B, Liggett E, Jones R, Lodeiro C, Dodoo C, Tyroch A. Comparison of robotic revisional weight loss surgery and laparoscopic revisional weight loss surgery using the MBSAQIP database. Surg Obes Relat Dis 2019; 15:909-919. [DOI: 10.1016/j.soard.2019.03.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 03/13/2019] [Accepted: 03/17/2019] [Indexed: 12/16/2022]
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22
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Less Morbidity with Robot-Assisted Gastric Bypass Surgery than with Laparoscopic Surgery? Obes Surg 2018; 29:519-525. [DOI: 10.1007/s11695-018-3545-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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23
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Wang L, Yao L, Yan P, Xie D, Han C, Liu R, Yang K, Guo T, Tian L. Robotic Versus Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity: a Systematic Review and Meta-Analysis. Obes Surg 2018; 28:3691-3700. [DOI: 10.1007/s11695-018-3458-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Lundberg PW, Wolfe S, Seaone J, Stoltzfus J, Claros L, El Chaar M. Robotic gastric bypass is getting better: first results from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Surg Obes Relat Dis 2018; 14:1240-1245. [PMID: 30580769 DOI: 10.1016/j.soard.2018.05.022] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/30/2018] [Accepted: 05/26/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND The use of robotic platforms in performing laparoscopic Roux-en-Y gastric bypass (LRYGB) is increasing, though their safety compared with the conventional laparoscopic approach remains unclear. OBJECTIVE The objective of this study was to evaluate perioperative data and 30-day outcomes of conventional and robot-assisted LRYGB using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. SETTING University health network, United States. METHODS We reviewed all conventional and robot-assisted LRYGB cases entered between January 1 and December 31, 2016 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. Demographic characteristics and 30-day outcomes were analyzed based on separate Mann-Whitney rank sums tests, χ2, or Fisher's exact tests as appropriate, with P ≤ .05 denoting statistical significance with no adjustment for multiple testing. RESULTS Of the 39,425 patients who underwent LRYGB, 2822 were robot-assisted. The robot-assisted approach required significantly more time (138 versus 108 min, P < .0001). Rates of organ space infection, bleeding, and other significant adverse events after the conventional and robot-assisted approaches were .3% versus .5% (P = .13), 1.1% versus .8% (P = .11), and 2.3% versus 2.3% (P = .96), respectively. There were also no significant differences in the rates of mortality, length of stay, reoperation, or readmission between the 2 groups. CONCLUSIONS Robot-assisted LRYGB is an increasingly popular alternative to the conventional laparoscopic approach. According to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, the early safety of these 2 techniques is equal, although the robotic approach requires more operative time.
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Affiliation(s)
| | - Samantha Wolfe
- St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Jacqueline Seaone
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Jill Stoltzfus
- St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Leonardo Claros
- St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Maher El Chaar
- St. Luke's University Health Network, Bethlehem, Pennsylvania
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25
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Gutierrez M, Ditto R, Roy S. Systematic review of operative outcomes of robotic surgical procedures performed with endoscopic linear staplers or robotic staplers. J Robot Surg 2018; 13:9-21. [PMID: 29744808 PMCID: PMC6397135 DOI: 10.1007/s11701-018-0822-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/30/2018] [Indexed: 02/08/2023]
Abstract
A comprehensive review of operative outcomes of robotic surgical procedures performed with the da Vinci robotic system using either endoscopic linear staplers (ELS) or robotic staplers is not available in the published literature. We conducted a literature search to identify publications of robotic surgical procedures in all specialties performed with either ELS or robotic staplers. Twenty-nine manuscripts and six abstracts with relevant information on operative outcomes published from January 2011 to September 2017 were identified. Given the relatively recent market release of robotic staplers in 2014, comparative perioperative clinical outcomes data on the performance of ELS vs. robotic staplers in robotic surgery is very sparse in the published literature. Only three comparative studies of surgeries with the da Vinci robotic system plus ELS vs. da Vinci plus robotic staplers were identified; two in robotic colorectal surgery and the other in robotic gastric bypass surgery. These comparative studies illustrate some nuances in device design and usability, which may impact outcomes and cost, and therefore may be important to consider when selecting the appropriate stapling technologies/technique for different robotic surgeries. Comparative perioperative data on the use of ELS vs. robotic staplers in robotic surgery is scarce (three studies), and current literature identifies both types of devices as safe and effective. Given the longer clinical history of ELS and its relatively more robust evidence base, there may be trade-offs to consider before switching to robotic staplers in certain robotic procedures. However, this literature review may serve as an initial reference for future research.
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Reddy RM, Gorrepati ML, Oh DS, Mehendale S, Reed MF. Robotic-Assisted Versus Thoracoscopic Lobectomy Outcomes From High-Volume Thoracic Surgeons. Ann Thorac Surg 2018; 106:902-908. [PMID: 29704479 DOI: 10.1016/j.athoracsur.2018.03.048] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 03/14/2018] [Accepted: 03/20/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Reports of surgical outcomes comparing proficient surgeons who perform either robotic-assisted or video-assisted thoracoscopic lobectomy are lacking. We evaluate the comparative effectiveness of robotic-assisted and video-assisted thoracoscopic lobectomies by surgeons who performed 20 or more annual surgical procedures in a national database. METHODS Patients 18 years or older, who underwent elective lobectomy by surgeons who performed 20 or more annual lobectomies by robotic-assisted or thoracoscopic approach from January 2011 through September 2015, were identified in the Premier Healthcare database with the use of codes from the ninth revision of the International Statistical Classification of Diseases and Related Health Problems. Propensity-score matching based on patient and hospital characteristics and by year was performed 1:1 to identify comparable cohorts for analysis (n = 838 in each cohort). All tests were two-sided, with statistical significance set at p less than 0.05. RESULTS A total of 23,779 patients received an elective lobectomy during the study period: 9,360 were performed by video-assisted thoracoscopic approach and 2,994 were by robotic-assisted approach. Propensity-matched comparison of lobectomies performed by surgeons who performed 20 or more procedures annually (n = 838) showed that robotic-assisted procedures had a longer mean operative time by 25 minutes (mean 247.1 minutes vs 222.6 minutes, p < 0.0001) but had a lower conversion-to-open rate (4.8% vs 8.0%, p = 0.007) and a lower 30-day complication rate (33.4% vs 39.2%, p = 0.0128). Transfusion rates and 30-day mortality rates were similar between the two cohorts. CONCLUSIONS When surgical outcomes are limited to surgeons who perform 20 or more annual procedures, the robotic-assisted approach is associated with a lower conversion-to-open rate and lower 30-day complication rate when than video-assisted thoracoscopic surgeons, with a mean operative time difference of 25 minutes.
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Affiliation(s)
- Rishindra M Reddy
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan.
| | | | - Daniel S Oh
- Clinical Affairs, Intuitive Surgical, Inc, Sunnyvale, California; Division of Thoracic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Shilpa Mehendale
- Clinical Affairs, Intuitive Surgical, Inc, Sunnyvale, California
| | - Michael F Reed
- Division of Thoracic Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Sharma G, Strong AT, Tu C, Brethauer SA, Schauer PR, Aminian A. Robotic platform for gastric bypass is associated with more resource utilization: an analysis of MBSAQIP dataset. Surg Obes Relat Dis 2017; 14:304-310. [PMID: 29276076 DOI: 10.1016/j.soard.2017.11.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/14/2017] [Accepted: 11/15/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND The current literature comparing robot-assisted Roux-en-Y gastric bypass (RA-RYGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) is limited to single center retrospective series. OBJECTIVES This study aims to compare perioperative outcomes of patients who underwent RA-RYGB with those who underwent LRYGB. SETTING National database. METHODS Data on patients who underwent RA-RYGB and LRYGB were extracted from the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant use file. A 1:8 propensity score matching (RA-RYGB:LRYGB) was performed, and the 30-day outcomes of the propensity-matched cohorts were compared. RESULTS In total, 36,158 patients met inclusion criteria, including 2660 RA-RYGB (7.4%) cases, which were propensity matched (1:8) with 21,280 LRYGB cases having similar preoperative characteristics. RA-RYGB was associated with longer median operative time (136 versus 107 min; P<.001) and a higher 30-day readmission rate (7.3% versus 6.2%; P = .03). There were no statistical differences between the RA-RYGB and LRYGB cohorts with respect to all-cause morbidity (10.6% versus 10.7%; P = .8), serious morbidity (1.2% versus 1.7%; P = .07), mortality (0.1% versus .2%; P = .2), unplanned intensive care unit admission (1.1% versus 1.3%; P = .3), reoperation (2.4% versus 2.4%; P = .97), or reintervention (3.0% versus 2.5%; P = .2) within 30 days after surgery. CONCLUSION Based on available national data, RA-RYGB appears safe compared with a conventional laparoscopic approach for gastric bypass. However, RA-RYGB was associated with longer operative time and higher readmission rate, indicating greater resource use. Further studies are needed to better delineate the role of robotic platforms in bariatric surgery.
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Affiliation(s)
- Gautam Sharma
- Metabolic and Bariatric Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Andrew T Strong
- Metabolic and Bariatric Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Chao Tu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Stacy A Brethauer
- Metabolic and Bariatric Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Philip R Schauer
- Metabolic and Bariatric Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ali Aminian
- Metabolic and Bariatric Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio.
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Stefanidis D, Bailey SB, Kuwada T, Simms C, Gersin K. Robotic gastric bypass may lead to fewer complications compared with laparoscopy. Surg Endosc 2017; 32:610-616. [DOI: 10.1007/s00464-017-5710-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 07/05/2017] [Indexed: 12/18/2022]
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Jung MK, Hagen ME, Buchs NC, Buehler LH, Morel P. Robotic bariatric surgery: A general review of the current status. Int J Med Robot 2017; 13. [DOI: 10.1002/rcs.1834] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 03/11/2017] [Accepted: 04/04/2017] [Indexed: 12/16/2022]
Affiliation(s)
- Minoa K. Jung
- Division of Digestive and Transplant Surgery; Department of Surgery; University Hospital Geneva; Geneva Switzerland
| | - Monika E. Hagen
- Division of Digestive and Transplant Surgery; Department of Surgery; University Hospital Geneva; Geneva Switzerland
| | - Nicolas C. Buchs
- Division of Digestive and Transplant Surgery; Department of Surgery; University Hospital Geneva; Geneva Switzerland
| | - Leo H. Buehler
- Division of Digestive and Transplant Surgery; Department of Surgery; University Hospital Geneva; Geneva Switzerland
| | - Philippe Morel
- Division of Digestive and Transplant Surgery; Department of Surgery; University Hospital Geneva; Geneva Switzerland
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30
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Charalampakis V, Daskalakis M, Singhal R. Comment on: "The Results of 100 Robotic Versus 100 Laparoscopic Gastric Bypass Procedures: a Single High Volume Centre Experience" by Smeenk et al. Obes Surg 2016; 27:200-201. [PMID: 27747457 DOI: 10.1007/s11695-016-2425-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- V Charalampakis
- Bariatric Unit, Department of General Surgery, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham, B9 5SS, UK.
| | - M Daskalakis
- Bariatric Unit, Department of General Surgery, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham, B9 5SS, UK
| | - R Singhal
- Bariatric Unit, Department of General Surgery, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham, B9 5SS, UK
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31
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Robotic Versus Laparoscopic Bariatric Surgery: a Systematic Review and Meta-Analysis. Obes Surg 2016; 26:3031-3044. [DOI: 10.1007/s11695-016-2408-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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32
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Liu R, Zhang T, Zhao ZM, Tan XL, Zhao GD, Zhang X, Xu Y. The surgical outcomes of robot-assisted laparoscopic pancreaticoduodenectomy versus laparoscopic pancreaticoduodenectomy for periampullary neoplasms: a comparative study of a single center. Surg Endosc 2016; 31:2380-2386. [PMID: 27631318 DOI: 10.1007/s00464-016-5238-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 08/16/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a difficult and complex operation. The introduction of robotics has opened up new angles in pancreatic surgery. This study aims to assess the surgical outcomes of robot-assisted laparoscopic pancreaticoduodenectomy relative to its laparoscopic counterpart. METHODS A retrospective study was designed to compare the surgical outcomes of 27 robot-assisted laparoscopic pancreaticoduodenectomy (RPD) and 25 laparoscopic pancreaticoduodenectomy (LPD). Perioperative data, including operating time, complication, morbidity and mortality, estimated blood loss, and postoperative length of stay, were analyzed. RESULTS The robotic group exhibited significantly shorter operative time (mean 387 vs. 442 min), shorter hospital stay (mean 17 vs. 24 days), and less blood loss (mean 219 vs. 334 ml) than those in the LPD group. No statistical difference was observed between the two groups in terms of complication rate, mortality rate, R0 resection rate, and number of harvested lymph node. CONCLUSIONS RPD is more efficient and secure process than LPD among properly selected patients. RPD is therefore a feasible alternative to the laparoscopic procedure. Further studies are needed to evaluate the cost effectiveness of the robotic approach for PD.
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Affiliation(s)
- Rong Liu
- Department of Hepatobiliary and Pancreatic Surgical Oncology, Chinese PLA General Hospital and Chinese PLA Medical School, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Tao Zhang
- Department of Hepatobiliary and Pancreatic Surgical Oncology, Chinese PLA General Hospital and Chinese PLA Medical School, 28 Fuxing Road, Haidian District, Beijing, 100853, China.,Department of General Surgery, 306 Hospital of PLA, Beijing, China
| | - Zhi-Ming Zhao
- Department of Hepatobiliary and Pancreatic Surgical Oncology, Chinese PLA General Hospital and Chinese PLA Medical School, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Xiang-Long Tan
- Department of Hepatobiliary and Pancreatic Surgical Oncology, Chinese PLA General Hospital and Chinese PLA Medical School, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Guo-Dong Zhao
- Department of Hepatobiliary and Pancreatic Surgical Oncology, Chinese PLA General Hospital and Chinese PLA Medical School, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Xuan Zhang
- Department of Hepatobiliary and Pancreatic Surgical Oncology, Chinese PLA General Hospital and Chinese PLA Medical School, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Yong Xu
- Department of Hepatobiliary and Pancreatic Surgical Oncology, Chinese PLA General Hospital and Chinese PLA Medical School, 28 Fuxing Road, Haidian District, Beijing, 100853, China
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Robotic-Assisted Versus Laparoscopic Colectomy Results in Increased Operative Time Without Improved Perioperative Outcomes. J Gastrointest Surg 2016; 20:1503-10. [PMID: 26966028 DOI: 10.1007/s11605-016-3124-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 02/29/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Interest in robotic technology is burgeoning within the field of colorectal surgery. However, benefits of robotic-assisted colectomy (RAC) compared with laparoscopic colectomy (LC) remain ambiguous. STUDY DESIGN Patients who underwent minimally invasive colectomy during 2012-2013 were identified from the National Surgical Quality Improvement Program (NSQIP) database. Short-term perioperative outcomes were compared between 1:1 propensity-matched groups. A subset analysis was performed among patients who underwent segmental resections. RESULTS Among the 15,976 patients included, 498 (3.1 %) colectomies were performed with robotic assistance. After matching for demographic, clinical, and treatment characteristics, there were no differences between RAC and LC in complications such as wound infection, urinary tract infection, cardiopulmonary or thromboembolic events, renal insufficiency, anastomotic leaks, transfusions, readmissions, or 30-day mortality (all p > 0.05). However, operative time was markedly higher for RAC (196 vs. 166 min, p < 0.001). Among segmental resections, operative time remained significantly longer for RAC (190 vs. 153 min, p < 0.001) without differences in perioperative outcomes (all p > 0.05). CONCLUSION In this early experience, RAC resulted in similar perioperative outcomes when compared to LC but was associated with longer operative time. Given the focus on value-based healthcare, utilizing RAC in straightforward colectomies may not be financially justifiable at this stage of adoption.
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