Textbook outcome and survival of robotic versus laparoscopic total gastrectomy for gastric cancer: a propensity score matched cohort study

Textbook outcome and textbook oncological outcome in esophagogastric cancer surgery - A systematic scoping review

INTRODUCTION

Quality assurance in esophagogastric surgery, particularly in an oncological context, is important, especially as long-term survival is highly affected by the short-term outcomes. Textbook Outcome (TO) and Textbook Oncological Outcome (TOO) serve as multidimensional metrics to assess surgical quality by evaluating various perioperative factors, as well as oncological outcomes. TO and TOO have been associated with improved long-term survival.

AIM

This study aimed to examine the incidence of, and the definitions of TO and TOO used in esophagogastric oncological surgery.

METHODS

This systematic scoping review followed the PRISMA 2020 guidelines and the PRISMA scoping review extension. The AMSTAR-2 was used to rate the review. A comprehensive systematic search was performed in Medline, Embase, and Web of Science and results were screened through Covidence. Quality assessment was conducted using the Newcastle-Ottawa scale.

RESULTS

A total of 55 observational cohort studies on esophagogastric cancer surgery were included. A total of 245,075 patients was included in the assessment of the achievement of TO and TOO. The rate of TO achievement ranged from 20.4 to 84.2 %, while the rate of TOO achievement ranged from 21.3 to 57.6 %. TO and TOO definitions varied widely, combining a median of nine (range: 4-11) parameters with a total of 45 different parameters being reported.

CONCLUSION

This systematic scoping review showed significant variations in incidence and in the definitions used for TO and TOO in esophagogastric cancer surgery between the included studies. This highlights the importance of standardizing the definitions of TO and TOO.

Textbook outcome in ovarian cancer and its impact on survival: comparative study

INTRODUCTION

Patients who achieve the textbook outcome (TO) present an uneventful postoperative course. Obtaining TO has also been related to better survival in oncological patients. Information about TO in patients with peritoneal carcinomatosis from ovarian cancer who undergo surgery is very scarce. Our objective was investigate TO in patients with carcinomatosis of ovarian origin who underwent interval surgery with or without HIPEC (TOOC) and its impact on survival.

METHODS

A multicenter study was performed between 2010 and 2015. Inclusion criteria were > 18 years old, with ovarian cancer and peritoneal carcinomatosis, who underwent scheduled surgery after response to neoadjuvant therapy. The criteria to establish TOOC were no major complications, no mortality, non-prolonged stay (p75:10 days), complete cytoreduction (CC-0), and no readmission.

RESULTS

365 patients were included, and TOOC was achieved in 204 (55.9%) patients. CC-0 cytoreduction was obtained in 312(85.5%). 7 patients (1.9%) died. 71 (19.5%) presented major complications (≥ IIIa). The readmission rate was 9.3%, and 24.9% of the patients presented a prolonged stay. The parameter with most significant negative impact on achieving TOOC was length of stay. Multivariate analysis confirmed postsurgical PCI, age, HIPEC, and time of surgery in minutes as an independent factor of TOOC. Survival analysis showed that patients who achieved TOOC had better overall survival (41 months (24.5- 67) versus 27 months (14-48.2) (p < 0.0001).

CONCLUSION

TO is an easy and valuable management tool for evaluating and comparing results obtained at different centers after surgery for peritoneal carcinomatosis of locally advanced ovarian cancer. Achieving TOOC benefits overall survival.

Optimizing surgical outcomes in gastric cancer: a comparison of laparoscopic and open total gastrectomy

BACKGROUND

The efficacy of the laparoscopic approach for total gastrectomy (TG) in Western countries remains under discussion. Recently, textbook outcome (TO) has gained recognition as a comprehensive measure of quality of care in upper gastrointestinal surgery. Although predictive factors for TO after TG are well documented, the influence of the surgical approach requires further analysis. This study aimed to compare the TO completion rate after TG for gastric cancer between the open (OTG) and laparoscopic TG (LTG) approaches.

METHODS

TO was defined by 10 criteria: (1) absence of intraoperative complications, (2) macroscopically complete resection, (3) R0 margin, (4) retrieval of ≥15 lymph nodes, (5) absence of postoperative complications with Clavien-Dindo grade ≥ 2, (6) no surgical reintervention within 30 days, (7) no unplanned intensive care unit admission within 30 days, (8) no mortality within 30 days, (9) length of stay ≤ 21 days, and (10) no readmission within 30 days. Propensity score matching was used to adjust for potential selection bias. Predictive factors associated with TO were identified through univariate and multivariate analyses.

RESULTS

Among the 188 patients, 34 underwent LTG. TO was achieved in 46.8% of cases, with no significant difference between OTG and LTG (45.5% vs 52.9%; P =.43). After propensity score matching, similar outcomes were observed (44.1% vs 52.9%; P =.47). However, LTG was associated with fewer postoperative complications of Clavien-Dindo grade ≥ 2 (P =.049), particularly pulmonary complications (P =.041).

CONCLUSION

This study confirms the feasibility and safety of LTG for cancer. The laparoscopic approach yields a TO completion rate comparable with that of the open approach while reducing postoperative complications.

Robotic Versus Laparoscopic Gastrectomy for Gastric Cancer: The Largest Systematic Reviews of 68,755 Patients and Meta-analysis

BACKGROUND

This meta-analysis aimed to compare the efficacy of robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) in treating gastric cancer (GC).

PATIENTS AND METHODS

A comprehensive literature search across PubMed, MEDLINE, and Web of Science identified 86 eligible studies, including 68,755 patients (20,894 in the RG group and 47,861 in the LG group).

RESULTS

The analysis revealed that RG was associated with superior outcomes in several areas: more lymph nodes were harvested, intraoperative blood loss was reduced, postoperative hospital stays were shorter, and the time to first flatus and oral intake was shortened (all p < 0.001). Additionally, RG resulted in lower incidences of conversion to open surgery (OR = 0.62, p = 0.004), reoperation (OR = 0.68, p = 0.010), overall postoperative complications (OR = 0.82, p < 0.001), severe complications (OR = 0.65, p < 0.001), and pancreatic complications (OR = 0.60, p = 0.004). However, RG had longer operative times and higher costs (both p < 0.001). No significant differences were found between RG and LG in terms of resection margin distance, mortality, anastomotic leakage, or recurrence rates.

CONCLUSIONS

RG is a safe and effective surgical option for patients of GC, but further improvements in operative duration and costs are needed.

Effect of Minimally Invasive Gastrectomy on Return to Intended Oncologic Therapy for Gastric Cancer

BACKGROUND

Adjuvant chemotherapy offers survival benefit to patients with gastric cancer. Only 50-65% of patients who undergo neoadjuvant chemotherapy and gastrectomy are able to receive adjuvant therapy. It is optimal to start adjuvant therapy within 8 weeks after gastrectomy. We compared the rate of return to intended oncologic therapy (RIOT) between minimally invasive gastrectomy (MIG) and open gastrectomy (OG).

METHOD

Retrospectively, we analyzed patients who underwent gastrectomy within a multi-hospital university-based health system (2019-2022). Data on patient demographics, comorbid conditions, operative approach, and postoperative outcomes were assessed with univariate analysis and multivariable analysis (MVA) to determine the association with RIOT.

RESULTS

Among 87 eligible patients, 33 underwent MIG and 54 underwent OG. There were no differences in demographics, performance status, comorbid conditions, or type of gastrectomy between the two groups. MIG patients were significantly more likely to RIOT compared with OG patients (87.9% vs. 63%, p = 0.003), with 73.1% of MIG patients starting adjuvant therapy within 8 weeks compared with 53.1% of OG patients. Factors associated with higher odds of RIOT included MIG and age <65 years, while major postoperative complications (Clavien-Dindo grade ≥IIIa) was associated with lower odds of RIOT. On MVA, MIG was independently associated with higher odds of RIOT compared with OG (odds ratio 6.05, 95% confidence interval 1.47-24.78, p = 0.008).

CONCLUSION

The minimally invasive approach may benefit patients undergoing gastrectomy, irrespective of the extent of gastric resection for adenocarcinoma. MIG is associated with a higher likelihood of (1) RIOT and (2) starting adjuvant therapy within the optimal time period after gastrectomy.

Short-Term Outcomes Analysis Comparing Open, Lap-Assisted, Totally Laparoscopic, and Robotic Total Gastrectomy for Gastric Cancer: A Network Meta-Analysis

BACKGROUND/OBJECTIVES

Total gastrectomy (TG) is the cornerstone treatment for gastric cancer (GC). While open TG (OTG) with D2 lymphadenectomy remains the gold standard, alternative techniques such as lap-assisted TG (LATG), totally laparoscopic TG (TLTG), and robotic TG (RTG) have been reported with promising outcomes. The present analysis aimed to compare the short-term outcomes of different techniques for TG comprehensively in the setting of GC.

METHODS

A systematic review and network meta-analysis were performed. The primary outcomes were overall complications (OC), severe postoperative complications (SPCs), and anastomotic leak (AL). Pooled effect-size measures included risk ratio (RR), weighted mean difference (WMD), and 95% credible intervals (CrIs).

RESULTS

Sixty-eight studies (44,689 patients) were included. Overall, 52.4% underwent OTG, 6.5% LATG, 39.2% TLTG, and 1.9% RTG. Both TLTG (RR 0.82; 95% CrI 0.73-0.92) and RTG (RR 0.75; 95% CrI 0.59-0.95) showed a reduced rate of postoperative OC compared to OTG. SPCs and AL RR were comparable across all techniques. Despite the longer operative time, LATG, TLTG, and RTG showed reduced intraoperative blood loss, time to first flatus, ambulation, liquid diet resumption, and hospital stay compared to OTG.

CONCLUSIONS

Minimally invasive approaches seem to be associated with improved OC and functional outcomes compared to OTG.

How to measure quality of surgery as a component of multimodality treatment of gastric cancer

Gastric cancer (GC) is one of the most frequent reasons for cancer-related death worldwide. The multimodal therapeutic strategies are now pragmatically tailored to each patient, especially in advanced GC. A radical but safe gastrectomy remains the cornerstone of the GC treatment. Moreover, the quality-of-life (QoL) outcome measures are now routinely utilized in order to select optimal type of gastrectomy, as well as reconstruction method. Postoperative complications are frequent, and effective diagnosis and treatment of complications is crucial to lower the mortality rates. The postoperative complications prolong hospital stay and may result in poor QoL, thus eliminating the completion of perioperative adjuvant therapy. Therefore, avoiding morbidity is not only relevant for the immediate postoperative course, but can also affect long-term oncological outcome. Measuring outcome enables surgeons to: monitor their own results; compare quality of treatment between centres; facilitate improvement both for surgery alone and combined treatment; select optimal procedure for an individual patient. Textbook oncological outcome is a composite quality measure representing the ideal hospitalization for gastrectomy, as well as stage-appropriate (perioperative) adjuvant chemotherapy. Standardized system for recording complications and adherence to multimodality treatment guidelines are crucial for achieving the ultimate goal of surgical quality-improvement that can benefit patients QoL and long-term outcomes after fast and uneventful hospitalization for gastrectomy.

A systematic review on the effectiveness of robot-assisted minimally invasive gastrectomy

BACKGROUND

Robot-assisted minimally invasive gastrectomy (RAMIG) is increasingly used as a surgical approach for gastric cancer. This study assessed the effectiveness of RAMIG and studied which stages of the IDEAL-framework (1 = Idea, 2A = Development, 2B = Exploration, 3 = Assessment, 4 = Long-term follow-up) were followed.

METHODS

The Cochrane Library, Embase, Pubmed, and Web of Science were searched for studies on RAMIG up to January 2023. Data collection included the IDEAL-stage, demographics, number of participants, and study design. For randomized controlled trials (RCTs) and long-term studies, data on intra-, postoperative, and oncologic outcomes, survival, and costs of RAMIG were collected and summarized.

RESULTS

Of the 114 included studies, none reported the IDEAL-stage. After full-text reading, 18 (16%) studies were considered IDEAL-2A, 75 (66%) IDEAL-2B, 4 (4%) IDEAL-3, and 17 (15%) IDEAL-4. The IDEAL-stages were followed sequentially (2A-4), with IDEAL-2A studies still ongoing. IDEAL-3 RCTs showed lower overall complications (8.5-9.2% RAMIG versus 17.6-19.3% laparoscopic total/subtotal gastrectomy), equal 30-day mortality (0%), and equal length of hospital stay for RAMIG (mean 5.7-8.5 days RAMIG versus 6.4-8.2 days open/laparoscopic total/subtotal gastrectomy). Lymph node yield was similar across techniques, but RAMIG incurred significantly higher costs than laparoscopic total/subtotal gastrectomy ($13,423-15,262 versus $10,165-10,945). IDEAL-4 studies showed similar or improved overall/disease-free survival for RAMIG.

CONCLUSION

During worldwide RAMIG implementation, the IDEAL-framework was followed in sequential order. IDEAL-3 and 4 long-term studies showed that RAMIG is similar or even better to conventional surgery in terms of hospital stay, lymph node yield, and overall/disease-free survival. In addition, RAMIG showed reduced postoperative complication rates, despite higher costs.

Textbook outcome for evaluating the surgical quality of gastrectomy

BACKGROUND

The textbook outcome (TO) is an indicator to evaluate surgical quality based on clinical, pathological, and surgical outcomes.

OBJECTIVE

To analyze the frequency, factors associated with achievement, and the prognostic impact of TO in gastric cancer treatment.

METHODS

Retrospective analysis of patients with gastric cancer operated with curative intent from 2009 to 2022 in a reference Cancer Center.

RESULTS

During the period, 681 patients were included and 444 (65.2%) achieved TO. Major surgical complications were the most common not-achieved outcome (16.4%) and intraoperative complications were the most achieved (96.2%). Most of the patients have failed in only 1 outcome (n = 105, 44.3%). Failure to achieve TO was associated with Charlson-Deyo comorbidity index ≥1 (46.4% vs 34.7%, p = 0.003), American Society of Anesthesiologists classification III/IV (40.1% vs 24.1%, p < 0.001), higher mean neutrophil-to-lymphocyte ratio (2.7 vs 3.3, p = 0.024), D1 lymphadenectomy (26.2% vs 15.8%, p = 0.001), and elective postoperative Intensive Care Unit admission (46.4% vs 38.5%, p = 0.046). Disease-free and overall survival (both p < 0.001) were higher in the TO group even after the exclusion of cases with surgical mortality (p = 0.013 and p = 0.024, respectively).

CONCLUSIONS

TO was achieved in most of the cases and its failure was associated with poor clinical performance and it impacts both early surgical results as well as long-term survival.

Enlightenment of robotic gastrectomy from 527 patients with gastric cancer in the minimally invasive era: 5 years of optimizing surgical performance in a high-volume center - a retrospective cohort study

BACKGROUND

Learning curves have been used in the field of robotic gastrectomy (RG). However, it should be noted that the previous study did not comprehensively investigate all changes related to the learning curve. This study aims to establish a learning curve for radical RG and evaluate its effect on the short-term outcomes of patients with gastric cancer.

METHODS

The clinicopathological data of 527 patients who underwent RG between August 2016 and June 2021 were retrospectively analyzed. Learning curves related to the operation time and postoperative hospital stay were determined separately using cumulative sum (CUSUM) analysis. Then, the impact of the learning curve on surgical efficacy was analyzed.

RESULTS

Combining the CUSUM curve break points and technical optimization time points, the entire cohort was divided into three phases (patients 1-100, 101-250, and 251-527). The postoperative complication rate and postoperative recovery time tended to decrease significantly with phase advancement ( P <0.05). More extraperigastric examined lymph nodes (LN) were retrieved in phase III than in phase I (I vs. III, 15.12±6.90 vs. 17.40±7.05, P =0.005). The rate of LN noncompliance decreased with phase advancement. Textbook outcome (TO) analysis showed that the learning phase was an independent factor in TO attainment ( P <0.05).

CONCLUSION

With learning phase advancement, the short-term outcomes were significantly improved. It is possible that our optimization of surgical procedures could have contributed to this improvement. The findings of this study facilitate the safe dissemination of RG in the minimally invasive era.

Improvement of perioperative outcomes of gastric gastrointestinal stromal tumour (GIST) resections and the influence of minimal invasive surgery

BACKGROUND

Safety of minimally invasive surgery (MIS) for gastrointestinal stromal tumours (GISTs) is still under debate since it might increase the risk of tumour rupture, especially in larger tumours. The aim of this study was to investigate trends in treatment and perioperative outcomes of patients undergoing resections of gastric GISTs over time.

METHODS

This was a multicentre retrospective study of consecutive patients who underwent wedge resection or partial gastrectomy for localized gastric GIST at five GIST reference centres between January 2009 and January 2022. To evaluate changes in treatment and perioperative outcomes over time, patients were divided into four equal periods. Perioperative outcomes were analysed separately and as a novel composite measure textbook outcome (TO).

RESULTS

In total 385 patients were included. Patient and tumour characteristics did not change over time, except for median age (62-65-68-68 years, p = 0.002). The proportion of MIS increased (4.0%-9.8%-37.4%-53.0 %, p < 0.001). Postoperative complications (Clavien Dindo ≥2; 22%-15%-11%-10 %, p = 0.146), duration of admission (6-6-5-4 days, p < 0.001) and operating time (92-94-77-73 min, p = 0.007) decreased over time while TO increased (54.0%- 52.7%-65.9%-76.0 %, p < 0.001). No change was seen in perioperative ruptures (6.0%- 3.6%-1.6%-3.0 %, p = 0.499). MIS was correlated with less CD ≥ 2 complications (p = 0.006), shorter duration of admission (p < 0.001) and more TO (p < 0.001). Similar results were observed in tumours ≤5 cm and >5 cm.

CONCLUSION

A larger percentage of gastric GIST were treated with MIS over time. MIS was correlated with less complications, shorter duration of admission and more TO. Tumour rupture rates remained low over time.

Textbook Outcome of Delta-Shaped Anastomosis in Minimally Invasive Distal Gastrectomy for Gastric Cancer in 4,505 Consecutive Patients

PURPOSE

Textbook outcome is a comprehensive measure used to assess surgical quality and is increasingly being recognized as a valuable evaluation tool. Delta-shaped anastomosis (DA), an intracorporeal gastroduodenostomy, is a viable option for minimally invasive distal gastrectomy in patients with gastric cancer. This study aims to evaluate the surgical outcomes and calculate the textbook outcome of DA.

MATERIALS AND METHODS

In this retrospective study, the records of 4,902 patients who underwent minimally invasive distal gastrectomy for DA between 2009 and 2020 were reviewed. The data were categorized into three phases to analyze the trends over time. Surgical outcomes, including the operation time, length of post-operative hospital stay, and complication rates, were assessed, and the textbook outcome was calculated.

RESULTS

Among 4,505 patients, the textbook outcome is achieved in 3,736 (82.9%). Post-operative complications affect the textbook outcome the most significantly (91.9%). The highest textbook outcome is achieved in phase 2 (85.0%), which surpasses the rates of in phase 1 (81.7%) and phase 3 (82.3%). The post-operative complication rate within 30 d after surgery is 8.7%, and the rate of major complications exceeding the Clavien-Dindo classification grade 3 is 2.4%.

CONCLUSIONS

Based on the outcomes of a large dataset, DA can be considered safe and feasible for gastric cancer.

Robotic gastrectomy was reliable option for overweight patients with gastric cancer: a propensity score matching study

BACKGROUND

The role of minimally invasive surgery using robotics versus laparoscopy in resectable gastric cancer patients with a high body mass index (BMI) remains controversial.

METHODS

A total of 482 gastric adenocarcinoma patients with BMI ≥ 25 kg/m2 who underwent minimally invasive radical gastrectomy between August 2016 and December 2019 were retrospectively analyzed, including 109 cases in the robotic gastrectomy (RG) group and 321 cases in the laparoscopic gastrectomy (LG) group. Propensity score matching (PSM) with a 1:1 ratio was performed, and the perioperative outcomes, lymph node dissection, and 3-year overall survival (OS) and disease-free survival (DFS) rates were compared.

RESULTS

After PSM, 109 patients were included in each of the RG and LG groups, with balanced baseline characteristics. Compared with the LG group, the RG group had similar intraoperative estimated blood loss [median (IQR) 30 (20-50) vs. 35 (30-59) mL, median difference (95%CI) - 5 (- 10 to 0)], postoperative complications [13.8% vs. 18.3%, OR (95%CI) 0.71 (0.342 to 1.473)], postoperative recovery, total harvested lymph nodes [(34.25 ± 13.43 vs. 35.44 ± 14.12, mean difference (95%CI) - 1.19 (- 4.871 to 2.485)] and textbook outcomes [(81.7% vs. 76.1%, OR (95%CI) 1.39 (0.724 to 2.684)]. Among pathological stage II-III patients receiving chemotherapy, the initiation of adjuvant chemotherapy in the RG group was similar to that in the LG group [median (IQR): 28 (25.5-32.5) vs. 32 (27-38.5) days, median difference (95%CI) - 3 (- 6 to 0)]. The 3-year OS (RG vs. LG: 80.7% vs. 81.7%, HR = 1.048, 95%CI 0.591 to 1.857) and DFS (78% vs. 76.1%, HR = 0.996, 95%CI 0.584 to 1.698) were comparable between the two groups.

CONCLUSION

RG conferred comparable lymph node dissection, postoperative recovery, and oncologic outcomes in a selected cohort of patients with BMI ≥ 25 kg/m2.

Is the QCI framework suited for monitoring outcomes and costs in a teaching hospital using value-based healthcare principles? A retrospective cohort study

OBJECTIVES

The objective is to develop a pragmatic framework, based on value-based healthcare principles, to monitor health outcomes per unit costs on an institutional level. Subsequently, we investigated the association between health outcomes and healthcare utilisation costs.

DESIGN

This is a retrospective cohort study.

SETTING

A teaching hospital in Rotterdam, The Netherlands.

PARTICIPANTS

The study was performed in two use cases. The bariatric population contained 856 patients of which 639 were diagnosed with morbid obesity body mass index (BMI) <45 and 217 were diagnosed with morbid obesity BMI ≥45. The breast cancer population contained 663 patients of which 455 received a lumpectomy and 208 a mastectomy.

PRIMARY AND SECONDARY OUTCOME MEASURES

The quality cost indicator (QCI) was the primary measures and was defined asQCI = (resulting outcome * 100)/average total costs (per thousand Euros)where average total costs entail all healthcare utilisation costs with regard to the treatment of the primary diagnosis and follow-up care. Resulting outcome is the number of patients achieving textbook outcome (passing all health outcome indicators) divided by the total number of patients included in the care path.

RESULTS

The breast cancer and bariatric population had the highest resulting outcome values in 2020 Q4, 0.93 and 0.73, respectively. The average total costs of the bariatric population remained stable (avg, €8833.55, min €8494.32, max €9164.26). The breast cancer population showed higher variance in costs (avg, €12 735.31 min €12 188.83, max €13 695.58). QCI values of both populations showed similar variance (0.3 and 0.8). Failing health outcome indicators was significantly related to higher hospital-based costs of care in both populations (p <0.01).

CONCLUSIONS

The QCI framework is effective for monitoring changes in average total costs and relevant health outcomes on an institutional level. Health outcomes are associated with hospital-based costs of care.

Comparison of Short-term and Three-year Oncological Outcomes Between Robotic and Laparoscopic Gastrectomy for Gastric Cancer: A Large Multicenter Cohort Study

OBJECTIVE

To compare the short-term and long-term outcomes between robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) for gastric cancer.

BACKGROUND

The clinical outcomes of RG over LG have not yet been effectively demonstrated.

METHODS

This retrospective cohort study included 3599 patients with gastric cancer who underwent radical gastrectomy at eight high-volume hospitals in China from January 2015 to June 2019. Propensity score matching was performed between patients who received RG and LG. The primary end point was 3-year disease-free survival (DFS).

RESULTS

After 1:1 propensity score matching, 1034 pairs of patients were enrolled in a balanced cohort for further analysis. The 3-year DFS in the RG and LG was 83.7% and 83.1% ( P =0.745), respectively, and the 3-year overall survival was 85.2% and 84.4%, respectively ( P =0.647). During 3 years of follow-up, 154 patients in the RG and LG groups relapsed (cumulative incidence of recurrence: 15.0% vs 15.0%, P =0.988). There was no significant difference in the recurrence sites between the 2 groups (all P >0.05). Sensitivity analysis showed that RG had comparable 3-year DFS (77.4% vs 76.7%, P =0.745) and overall survival (79.7% vs 78.4%, P =0.577) to LG in patients with advanced (pathologic T2-4a) disease, and the recurrence pattern within 3 years was also similar between the 2 groups (all P >0.05). RG had less intraoperative blood loss, lower conversion rate, and shorter hospital stays than LG (all P >0.05).

CONCLUSIONS

For resectable gastric cancer, including advanced cases, RG is a safe approach with comparable 3-year oncological outcomes to LG when performed by experienced surgeons.

Comparison of survival benefit and safety between surgery following conversion therapy versus surgery alone in patients with surgically resectable hepatocellular carcinoma at CNLC IIb/IIIa stage: a propensity score matching study

OBJECTIVE

The objective of this study is to evaluate and compare the survival benefit and safety of surgery following conversion therapy versus surgery alone in patients diagnosed with surgically resectable hepatocellular carcinoma (HCC) at China Liver Cancer Staging (CNLC) IIb/IIIa stage.

METHODS

A total of 95 patients diagnosed with surgically resectable CNLC IIb/IIIa HCC were retrospectively enrolled in our study from November 2018 to December 2022. Among them, 30 patients underwent conversion therapy followed by hepatectomy, while the remaining 65 received surgery alone. The primary endpoint was recurrence-free survival (RFS). Propensity score matching was employed to minimize bias in the retrospective analysis.

RESULTS

Compared to the surgery alone group, the conversion therapy group demonstrated a significantly prolonged median RFS (17.1 vs. 7.0 months; P =0.014), a reduced incidence of microvascular invasion (MVI, 23.3 vs. 81.5%; P <0.001), and a comparable rate of achieving Textbook Outcome in Liver Surgery (TOLS, 83.3 vs. 76.9%; P =0.476). Multivariate analysis indicated that conversion therapy was independently associated with improved RFS after hepatectomy (HR=0.511, P =0.027). The same conclusions were obtained after propensity score matching.

CONCLUSIONS

The findings of our study offer preliminary evidence that preoperative conversion therapy significantly prolongs RFS in patients with surgically resectable HCC at CNLC IIb/IIIa stage. Furthermore, combining conversion therapy and hepatectomy represents a relatively safe treatment strategy.

Evaluation of optimum classification measures used to define textbook outcome among patients undergoing curative-intent resection of gastric cancer

BACKGROUND

Textbook outcome (TO) is a composite measure reflecting various aspects of services provided to patients with solid malignancies. We sought to evaluate the importance of various TO components previously proposed for gastric cancer.

METHODS

Prospectively maintained electronic databases of 1,743 patients treated in two academic surgical centres were reviewed. Six candidate definitions of TO were evaluated based on their ability to accurately predict patients' prognosis by Cox proportional hazards modelling.

RESULTS

TO definition combining 10 measures corresponding to complete tumour resection with an uneventful postoperative course showed the best goodness of fit by achieving the lowest values of Akaike (AIC) and Bayesian (BIC) information criteria and the best predictive performance based on the highest value of c-index. The overall median survival was significantly longer for patients with than without textbook outcome (69.0 vs 20.1 months, P < 0.001). TO maintained its prognostic value in a multivariate model controlling for age, sex, comorbidities, treatment, and tumour related variables and was associated with a 39% lower risk of death (HR 0.61, 95%CI 0.51 - 0.73, P < 0.001). Nine variables identified as predictors of TO were used to develop a nomogram showing very good correlation between the predicted and actual probability of achieving TO. The AUC of ROC obtained from the nomogram was 0.752 (95% CI 0.727 to 0.781).

CONCLUSIONS

A uniform definition of textbook outcome provides clinically relevant prognostic information and could be used in quality improvement programs for gastric cancer patients.

Textbook Oncological Outcome in European GASTRODATA

OBJECTIVE

To assess the rate of textbook outcome (TO) and textbook oncological outcome (TOO) in the European population based on the GASTRODATA registry.

BACKGROUND

TO is a composite parameter assessing surgical quality and strongly correlates with improved overall survival. Following the standard of treatment for locally advanced gastric cancer, TOO was proposed as a quality and optimal multimodal treatment parameter.

METHODS

TO was achieved when all the following criteria were met: no intraoperative complications, radical resection according to the surgeon, pR0 resection, retrieval of at least 15 lymph nodes, no severe postoperative complications, no reintervention, no admission to the intensive care unit, no prolonged length of stay, no postoperative mortality and no hospital readmission. TOO was defined as TO with the addition of perioperative chemotherapy compliance.

RESULTS

Of the 2558 patients, 1700 were included in the analysis. TO was achieved in 1164 (68.5%) patients. The use of neoadjuvant chemotherapy [odds ratio (OR) = 1.33, 95% CI: 1.04-1.70] and D2 or D2+ lymphadenectomy (OR = 1.55, 95% CI: 1.15-2.10) had a positive impact on TO achievement. Older age (OR = 0.73, 95% CI: 0.54-0.94), pT3/4 (OR = 0.79, 95% CI: 0.63-0.99), ASA 3/4 (OR = 0.68, 95% CI: 0.54-0.86) and total gastrectomy (OR = 0.56, 95% CI: 0.45-0.70), had a negative impact on TO achievement. TOO was achieved in 388 (22.8%) patients. Older age (OR = 0.37, 95% CI: 0.27-0.53), pT3 or pT4 (OR = 0.52, 95% CI: 0.39-0.69), and ASA 3 or 4 (OR = 0.58, 95% CI: 0.43-0.79) had a negative impact on TOO achievement.

CONCLUSIONS

Despite successively improved surgical outcomes, stage-appropriate chemotherapy in adherence to the current guidelines for multimodal treatment of gastric cancer remains poor. Further implementation of oncologic quality metrics should include greater emphasis on perioperative chemotherapy and adequate lymphadenectomy.

Textbook outcome in oncological gastric surgery: a systematic review and call for an international consensus

BACKGROUND

Textbook outcome (TO) is a multidimensional measure used to assess the quality of surgical practice. It is a reflection of an "ideal" surgical result, based on a series of benchmarks or established reference points that may vary depending on the pathology in question. References to TO in the literature are scarce, and the few reports that are available were all published very recently. In the case of gastric surgery, there is no established consensus on the parameters that should be included in TO, a circumstance that prevents comparison between series.

AIM

To present a review of the literature on TO in gastric surgery (TOGS) and to try to establish a consensus on its definition.

MATERIAL AND METHODS

Following the PRISMA guide, we performed an unlimited search for articles on TOGS in the MEDLINE (PubMed), EMBASE and Cochrane, Latindex, Scielo, and Koreamed databases, without language restriction, updated on December 31, 2022. The inclusion criterion was any type of study assessing TO in adult patients after oncological gastric surgery. Selected studies were assessed, and TOGS was measured. The parameters used to assess the achievement of TOGS in selected studies were also recorded.

RESULTS

Twelve articles were included, comprising a total of 44,581 patients who had undergone an oncological gastric resection. The median rate of TOGS was 38.6%. All the publications but one included mortality as a TO variable, showing statistically significant differences in favor of the group in which TOGS was achieved. All articles included the number of nodes examined in the surgical specimen, with the assessment of fewer than 15 being associated with a low rate of TOGS achievement in five studies (41.7%). The variable postoperative complications according to the Clavien-Dindo score was the most important cause of failure to achieve TOGS in four studies (33.3%). Seven articles (58.3%) found a significant increase in long-term survival in patients who obtained TO. Advanced age, elevated ASA, and Charlson score had a negative impact on obtaining TOGS.

CONCLUSIONS

The standardization of TOGS is necessary to be able to establish comparable results between groups.

Laparoscopic Versus Robotic Gastric Cancer Surgery: Short-Term Outcomes-Systematic Review and Meta-Analysis of 25,521 Patients

Background: Gastric cancer has the third highest cancer-related mortality worldwide. There is no consensus regarding the optimal surgical technique to perform curative resection surgery. Objective: Compare laparoscopic gastrectomy (LG) and robotic gastrectomy (RG) regarding short-term outcomes in patients with gastric cancer. Materials and Methods: This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the following topics: "Gastrectomy," "Laparoscopic," and "Robotic Surgical Procedures." The included studies compared short-term outcomes between LG and RG. Individual risk of bias was assessed with the Methodological Index for Non-Randomized Studies (MINORS) scale. Results: There was no significant difference between RG and LG regarding conversion rate, reoperation rate, mortality, overall complications, anastomotic leakage, distal and proximal resection margin distances, and recurrence rate. However, mean blood loss (mean difference [MD] -19.43 mL, P < .00001), length of hospital stay (MD -0.50 days, P = .0007), time to first flatus (MD -0.52 days, P < .00001), time to oral intake (MD -0.17 days, P = .0001), surgical complications with a Clavien-Dindo grade ≥III (risk ratio [RR] 0.68, P < .0001), and pancreatic complications (RR 0.51, P = .007) were significantly lower in the RG group. Furthermore, the number of retrieved lymph nodes was significantly higher in the RG group. Nevertheless, the RG group showed a significantly higher operation time (MD 41.19 minutes, P < .00001) and cost (MD 3684.27 U.S. Dollars, P < .00001). Conclusion: This meta-analysis supports the choice of robotic surgery over laparoscopy concerning relevant surgical complications. However, longer operation time and higher cost remain crucial limitations. Randomized clinical trials are required to clarify the advantages and disadvantages of RG.

Short-Term and Textbook Surgical Outcomes During the Implementation of a Robotic Gastrectomy Program

BACKGROUND

Whether gastric cancer patients derive greater benefit from robotic gastrectomy (RG), or open gastrectomy (OG) is unknown. We initiated a RG program in 2018, with prospective short-term outcome monitoring to ensure safety. We hypothesized that the RG program for gastric cancer can be safely implemented with equivalent safety and oncological textbook outcomes (TOs) to conventional open gastrectomy (OG).

METHODS

The study included patients who underwent curative-intent OG or RG for gastric adenocarcinoma between January 2018 and December 2021. TO metrics were negative surgical margins, ≥ 15 lymph nodes examined, no severe (Clavien-Dindo grade ≥ IIIa) postoperative complications, no reinterventions within 90 days after surgery, no ICU admission, no prolonged length of stay (LOS; > 10 days), no 90-day postoperative mortality, and no readmission within 90 days after surgery. Overall TO was achieved when all these metrics were met.

RESULTS

Of 161 patients, 120 underwent OG, and 41 underwent RG. The two groups' demographic and disease characteristics did not differ significantly. Compared with OG patients, RG patients had a longer median surgery time (348 vs. 282 min), smaller median blood loss volume (50 vs. 150 mL), lower mean prescribed opioid dose at discharge (12 vs. 45 mg), and shorter median LOS (4 vs. 7 days; all p < 0.001). The groups' postoperative complication rates (10% vs. 17%) did not differ significantly (p = 0.283). The overall TO rate of the RG group (73%) was higher than that of the OG group (60%), but the difference was not significant (p = 0.131).

CONCLUSION

We were able to implement the RG program safely, without compromising safety or oncological outcomes.

Intraoperative performance and outcomes of robotic and laparoscopic total gastrectomy for gastric cancer: A high-volume center retrospective propensity score matching study

BACKGROUND

Studies on robotic total gastrectomy (RTG) are currently limited. This study aimed to compare the intraoperative performance as well as short- and long-term outcomes of RTG and laparoscopic total gastrectomy (LTG).

METHODS

A total of 969 patients underwent robotic (n = 161) or laparoscopic (n = 636) total gastrectomy between October 2014 and October 2021. The two groups of patients were matched 1:3 using the propensity score matching (PSM) method. The intraoperative performance as well as short- and long-term outcomes of the robotic (n = 147) and the laparoscopic (n = 371) groups were compared.

RESULTS

After matching, the estimated intraoperative blood loss was lower (80.51 ± 68.77 vs. 89.89 ± 66.12, p = 0.008), and the total number of lymph node dissections was higher (34.74 ± 12.44 vs. 29.83 ± 12.22, p < 0.001) in the RTG group compared with the LTG group. More lymph node dissections at the upper edge of the pancreas were performed in the RTG group than in the LTG (12.59 ± 4.18 vs. 10.33 ± 4.58, p = 0.001). Additionally, postoperative recovery indicators and laboratory data were greater in the RTG group than those in the LTG group, while postoperative complications were comparable between the two groups (19.0% vs. 18.9%, p = 0.962). For overweight or obese patients with body mass indexes (BMIs) ≥25, certain clinical outcomes of the RTG remained advantageous, and no significant differences in three-year overall survival (OS) or relapse-free survival (RFS) were observed.

CONCLUSIONS

Robotic total gastrectomy demonstrated better intraoperative performance, could improve the short-term clinical outcomes of patients, and was more conducive to patient recovery. However, the long-term efficacies of the two approaches were similar. Robotic surgical systems may reduce surgical stress responses in patients, allowing them to receive postoperative chemotherapy sooner.

Textbook outcomes of hepatocellular carcinoma patients with sarcopenia: A multicenter analysis

BACKGROUND

The impact of sarcopenia on textbook outcome (TO) after hepatectomy in hepatocellular carcinoma (HCC) patients remains unclear. This study aimed to investigate the association between sarcopenia and TO, to clarify its long and short-term prognostic value, and to develop a nomogram model based on sarcopenia and TO for survival prediction.

METHODS

Patients who underwent HCC resection between January 2012 and March 2017 in three large hospitals in Fujian were retrospectively recruited and divided into sarcopenia and non-sarcopenia groups based on skeletal muscle index (SMI) values. TO was defined as no 30-day morality, no 30-day readmission, negative margins, no prolonged hospital stay, and no major complications. Multivariate regression was used to screen for clinical factors associated with TO. Nomograms of overall survival (OS) and recurrence-free survival (RFS) after hepatectomy for HCC were developed.

RESULTS

A total of 1172 patients were included in the study. The TO rates were 28.74% (121/421 patients) in the sarcopenia group and 43.4% (326/751 patients) in the non-sarcopenia group. The results showed that sarcopenia was an independent predictor of TO (p < 0.001), TO was an independent predictor of perioperative treatment-related sarcopenia (PTRS)(p = 0.002), and TO was an independent predictor of OS and RFS (p < 0.001). Nomogram models based on sarcopenia and TO were generated and accurately predicted OS and RFS at 1, 3, and 5 years.

CONCLUSION

Both sarcopenia and TO are independent predictors of OS and RFS after HCC resection. Sarcopenia was an independent predictor of TO. Sarcopenia influenced long-term survival by affecting short-term postoperative outcomes.

Clinical advantage of standardized robotic total gastrectomy for gastric cancer: a single-center retrospective cohort study using propensity-score matching analysis

BACKGROUND

Although recent studies have shown that robotic gastrectomy offers clinical advantages over laparoscopic gastrectomy in decreasing gastric cancer (GC) morbidity, studies focusing on robotic total gastrectomy (RTG) remain limited. The current study aimed to clarify whether the use of a robotic system could clinically improve short-term outcomes.

METHODS

Between January 2009 and June 2021, 371 patients diagnosed with both clinical and pathological Stage III or lower GC and underwent RTG or laparoscopic total gastrectomy (LTG) were enrolled in this study. The primary outcome was the incidence of intra-abdominal infectious complications over Clavien-Dindo classification grade IIIa. Demographic characteristics of those who underwent the RTG and LTG were matched using propensity-score matching (PSM), after which short-term outcomes were compared retrospectively.

RESULTS

After PSM, 100 patients were included in each group. The RTG group had a significantly shorter duration of hospitalization following surgery [RTG 13 (11-16) days vs. LTG 14 (11-19) days; p = 0.032] and a greater number of dissected LNs [RTG 48 (39-59) vs. LTG 43 (35-54) mL; p = 0.025], despite having a greater total operative time [RTG 511 (450-646) min vs. LTG 448 (387-549) min; p < 0.001]. In addition, the RTG group had significantly fewer total complications (3% vs. 13%, p = 0.019) and intra-abdominal infectious complications (1% vs. 9%; p = 0.023).

CONCLUSIONS

The current study showed that robotic surgery might improve short-term outcomes following minimally invasive radical total gastrectomy by reducing intra-abdominal infectious complications.

Modern surgical therapy for gastric cancer-Robotics and beyond

The surgical paradigm for gastric cancer has been changed from extended surgery to minimally invasive surgery. Laparoscopic surgery is a practical method for minimally invasive surgery for early gastric cancer, and the indication is expanding to advanced gastric cancer. In recent years, robotic gastrectomy has been highlighted as a breakthrough to overcome the drawbacks of laparoscopic gastrectomy. Here, we discuss the recent updates of modern surgical therapy for gastric cancer-robotics and beyond.

Comparison of Long-Term and Perioperative Outcomes of Robotic Versus Conventional Laparoscopic Gastrectomy for Gastric Cancer: A Systematic Review and Meta-Analysis of PSM and RCT Studies

Background

To investigate the perioperative and oncological outcomes of gastric cancer (GC) after robotic versus laparoscopic gastrectomy (RG versus LG), we carried out a meta-analysis of propensity score matching (PSM) studies and randomized controlled study (RCT) to compare the safety and overall effect of RG to LG for patients with GC.

Methods

PubMed, Web of Science, EMBASE, and Cochrane Central Register were searched based on a defined search strategy to identify eligible PSM and RCT studies before July 2021. Data on perioperative and oncological outcomes were subjected to meta-analysis.

Results

Overall, we identified 19 PSM studies and 1 RCT of RG versus LG, enrolling a total of 13,446 patients (6,173 and 7,273 patients underwent RG and LG, respectively). The present meta-analysis revealed nonsignificant differences in tumor size, proximal resection margin distance, distal resection margin distance, abdominal bleeding, ileus, anastomosis site leakage, duodenal stump leakage rate, conversion rate, reoperation, overall survival rate, and long-term recurrence-free survival rate between the two groups. Alternatively, comparing RG with LG, RG has a longer operative time (p < 0.00001), less blood loss (p <0.0001), earlier time to first flatus (p = 0.0003), earlier time to oral intake (p = 0.0001), shorter length of stay (p = 0.0001), less major complications (p = 0.0001), lower overall complications (p = 0.0003), more retrieved lymph nodes (P < 0.0001), and more cost (p < 0.00001).

Conclusions

In terms of oncological adequacy and safety, RG is a feasible and effective treatment strategy for gastric cancer but takes more cost in comparison with LG.

Current Status and Trends of Minimally Invasive Gastrectomy in Korea

Since its introduction in the early 1990s, laparoscopic gastrectomy has been widely accepted for the treatment of gastric cancer worldwide. In the last decade, the Korean Laparoendoscopic Gastrointestinal Surgery Study group performed important clinical trials and exerted various efforts to enhance the quality of scientific knowledge and surgical techniques in the field of gastric cancer surgery. Laparoscopic gastrectomy has shifted to a new era in Korea due to recent advances and innovations in technology. Here, we discuss the recent updates of laparoscopic gastrectomy—namely, reduced-port, single-incision, robotic, image-guided, and oncometabolic surgery.