Comparison of laparoscopic total gastrectomy and laparotomic total gastrectomy for gastric cancer

Outcomes of laparoscopic versus open total gastrectomy with D2 lymphadenectomy for gastric cancer: a systematic review and meta-analysis

Background

The effectiveness of laparoscopic total gastrectomy with D2 lymphadenectomy (LTGD2) remains controversial. This meta-analysis compares surgical and survival outcomes of LTGD2 and open total gastrectomy with D2 lymphadenectomy (OTGD2) for gastric cancer.

Methods

Controlled studies comparing LTGD2 and OTGD2 published before November 2021 were retrieved via database searches. We compared intraoperative outcomes, pathological data, postoperative outcomes, 5-year disease-free survival (DFS), and overall survival (OS).

Results

17 studies were included, containing 4742 patients. Compared with OTGD2, the LTGD2 group had less blood loss (mean difference [MD] = − 122.48; 95% CI: − 187.60, − 57.37; P = 0.0002), fewer analgesic medication (MD = -2.48; 95% CI: − 2.69, − 2.27; P < 0.00001), earlier first flatus (MD = − 1.03; 95% CI: − 1.80, − 0.26; P = 0.009), earlier initial food intake (MD = − 0.89; 95% CI: − 1.09, − 0.68; P < 0.00001) and shorter hospital stay (MD = − 3.24; 95% CI: − 3.75, − 2.73; P < 0.00001). The LTGD2 group had lower postoperative total complication ratio (OR = 0.76; 95% CI: 0.62, 0.92; P = 0.006), incision (OR = 0.50; 95% CI:0.31, 0.79; P = 0.003) and pulmonary (OR = 0.57; 95% CI: 0.34, 0.96; P = 0.03) complication rates, but similar rates of other complications and mortality. Total number of dissected lymph nodes were similar, but the number of No. 10 dissected nodes was less with LTGD2 (MD = − 0.31; 95% CI: − 0.46, − 0.16; P < 0.0001). There was no difference in 5-year OS (P = 0.19) and DFS (P = 0.34) between LTGD2 and OTGD2 groups.

Conclusions

LTGD2 produces small trauma, fast postoperative recovery and small length of hospital stays than OTGD2, and had similar long-term clinical efficacy as OTGD2. However, these results still need further high-quality prospective randomized controlled trials confirmation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00748-2.

Laparoscopic versus Open Surgery for Gastric Cancer in Western Countries: A Systematic Review and Meta-Analysis of Short- and Long-Term Outcomes

Background. The advantages of a laparoscopic approach for the treatment of gastric cancer have already been demonstrated in Eastern Countries. This review and meta-analysis aims to merge all the western studies comparing laparoscopic (LG) versus open gastrectomies (OG) to provide pooled results and higher levels of evidence. Methods. A systematic literature search was performed in MEDLINE(PubMed), Embase, WebOfScience and Scopus for studies comparing laparoscopic versus open gastrectomy in western centers from 1980 to 2021. Results. After screening 355 articles, 34 articles with a total of 24,098 patients undergoing LG (5445) or OG (18,653) in western centers were included. Compared to open gastrectomy, laparoscopic gastrectomy has a significantly longer operation time (WMD = 47.46 min; 95% CI = 31.83−63.09; p < 0.001), lower blood loss (WMD = −129.32 mL; 95% CI = −188.11 to −70.53; p < 0.0001), lower analgesic requirement (WMD = −1.824 days; 95% CI = −2.314 to −1.334; p < 0.0001), faster time to first oral intake (WMD = −1.501 days; 95% CI = −2.571 to −0.431; p = 0.0060), shorter hospital stay (WMD = −2.335; 95% CI = −3.061 to −1.609; p < 0.0001), lower mortality (logOR = −0.261; 95% the −0.446 to −0.076; p = 0.0056) and a better 3-year overall survival (logHR 0.245; 95% CI = 0.016−0.474; p = 0.0360). A slight significant difference in favor of laparoscopic gastrectomy was noted for the incidence of postoperative complications (logOR = −0.202; 95% CI = −0.403 to −0.000 the = 0.0499). No statistical difference was noted based on the number of harvested lymph nodes, the rate of major postoperative complication and 5-year overall survival. Conclusions. In Western centers, laparoscopic gastrectomy has better short-term and equivalent long-term outcomes compared with the open approach, but more high-quality studies on long-term outcomes are required.

Laparoscopic gastrectomy for early and advanced gastric cancer in a western center: a propensity score-matched analysis

The employment of laparoscopic gastrectomy (LG) in the management of gastric cancer (GC) is increasing. Despite recent results from randomized trials, its effectiveness and oncological results in different scenarios remain controversial, especially in western centers. The aim of this study was to compare the short-term outcomes and survival of LG with open gastrectomy (OG) for GC. We reviewed all GC patients who underwent curative gastrectomy from a prospective database. Propensity score-matched (PSM) analysis including 10 variables was conducted to reduce patient selection bias using a 1:1 case-control match. A total of 530 GC were eligible for inclusion (438 OG and 92 LG). Older age, lower hemoglobin levels, total gastrectomy, larger tumor size, greater depth of tumor invasion and advanced pTNM stage was more frequent in the OG group. After PMS analysis, 92 patients were matched in each group. All variables assigned in the score were well matched. LG group had a slightly higher number of retrieved lymph nodes (42.3 vs 37.6), however, without reaching statistical significance (p = 0.072). No differences were recorded about the frequency of major postoperative complications (POC) and mortality rates between OG and LG groups (12% vs 15.2%, p = 0.519, respectively). In survival analysis, after matching, there was no difference in survival between the two groups. Multivariate analysis showed that only ASA and pN stage were independent factor associated with survival after PSM. In conclusion, laparoscopic gastrectomy was a safe and effective surgical technique for gastric cancer, with short-term and oncological outcomes comparable to open surgery.

[Evidence in minimally invasive oncological gastric surgery]

BACKGROUND

The aim of this study was to systematically review the current evidence on laparoscopic and robotic distal and total gastrectomy in comparison to open surgery.

MATERIAL AND METHODS

A systematic search of EMBASE and PubMed was conducted and 197 randomized (RCT) and non-randomized (non-RCT) studies were identified. An evaluation of early gastric cancer (EGC) and advanced (AGC) gastric cancer was carried out.

RESULTS

For EGC and laparoscopic distal resection (LDG) and total gastrectomy (LTG) a total of 10 RCT and 6 non-RCT, including 4329 patients (laparoscopic 2010 vs. open 2319) were identified. At a high evidence level (1+, 1++) there was no significant difference in terms of feasibility, intraoperative outcome and oncological quality, mortality and long-term oncological outcome compared to open gastrectomy (OG). After LDG and LTG patients showed a significantly faster early postoperative recovery and lower total morbidity. In contrast, the operation times were significant longer compared to ODG and OTG. For distal AGC and LDG in 6 RCT, including 2806 patients (LDG 1410 vs. ODG 1369) comparable results could be found also with a high evidence level (1++). The evidence for LTG in cases of AGC was lower (2-, 2+). Currently ,only 6 non-RCT with a total of 1090 patients (LTG 539 vs. OTG 551) are available, which showed comparable results to LDG but further high-quality RCTs are necessary. Robotic gastrectomy (RG) is currently being evaluated. According to the first studies RG for EGC seems to be equivalent to LDG; however, the evidence is currently low (3 to 2-).

Early Red Flags Associated with Delayed Discharge in Patients Undergoing Gastrectomy: Analysis of Perioperative Variables and ERAS Protocol Items

BACKGROUND

Enhanced Recovery After Surgery (ERAS) perioperative pathways are safe and effective for patients undergoing gastrectomy. However, adherence to these protocols varies and is generally underreported. This retrospective study aimed to assess whether perioperative variables or deviation from ERAS items is associated with delayed discharge after gastrectomy.

METHODS

All patients undergoing gastrectomy at our institution were managed with a standardised perioperative pathway according to ERAS principles. The target length of stay was set as the ninth post-operative day (POD). All significant variables were derived from a bivariate analysis and were entered into a logistic regression to confirm their statistical value.

RESULTS

The study included 180 patients. Multivariate regression analysis revealed that incomplete immunonutrition, failure to extubate the patient at the end of surgery, intraoperative crystalloids >2150 ml and blood transfusion >268 ml, surgery duration >195 min, and failure to mobilise patients within 24 h from surgery were associated with delayed discharge. The logistic regression model was statistically significant (p < 0.001) and correctly classified 73.6% of cases. Sensitivity and specificity were 74.1% and 73.2%, respectively.

CONCLUSIONS

These results seem clinically significant and consistent with those of previous studies. The reported perioperative variables showed a strong relationship with the length of hospital stay.

Gastric partitioning for the treatment of malignant gastric outlet obstruction

BACKGROUND

Gastric outlet obstruction (GOO) is one of the main complications in stage IV gastric cancer patients. This condition is usually managed by gastrojejunostomy (GJ). However, gastric partitioning (GP) has been described as an alternative to overcoming possible drawbacks of GJ, such as delayed gastric emptying and tumor bleeding.

AIM

To compare the outcomes of patients who underwent GP and GJ for malignant GOO.

METHODS

We retrospectively analyzed 60 patients who underwent palliative gastric bypass for unresectable distal gastric cancer with GOO from 2009 to 2018. Baseline clinicopathological characteristics including age, nutritional status, body mass index, and performance status were evaluated. Obstructive symptoms were graded according to GOO score (GOOS). Surgical outcomes evaluated included duration of the procedure, surgical complications, mortality, and length of hospital stay. Acceptance of oral diet after the procedure, weight gain, and overall survival were the long-term outcomes evaluated.

RESULTS

GP was performed in 30 patients and conventional GJ in the other 30 patients. The mean follow-up was 9.2 mo. Forty-nine (81.6%) patients died during that period. All variables were similar between groups, with the exception of worse performance status in GP patients. The mean operative time was higher in the GP group (161.2 vs 85.2 min, P < 0.001). There were no differences in postoperative complications and surgical mortality between groups. The median overall survival was 7 and 8.4 mo for the GP and GJ groups, respectively (P = 0.610). The oral acceptance of soft solids (GOOS 2) and low residue or full diet (GOOS 3) were reached by 28 (93.3%) GP patients and 22 (75.9%) GJ patients (P = 0.080). Multivariate analysis demonstrated that GOOS 2 and GOOS 3 were the main prognostic factors for survival (hazard ratio: 8.90, 95% confidence interval: 3.38-23.43, P < 0.001).

CONCLUSION

GP is a safe and effective procedure to treat GOO. Compared to GJ, it provides similar surgical outcomes with a trend to better solid diet acceptance by patients.

Prognostic effect of different etiologies in patients with gastric cardia cancer

There are still many controversies about the characteristics and prognosis of gastric cardia cancer. We aimed to evaluate the clinical characteristics and outcome between cardia and noncardia cancer. Also, we evaluated the clinical outcome according to etiologic factors.We performed a retrospective cohort study of 92 patients with gastric cardia cancer from January 2003 to December 2013. The patients with noncardia cancer were selected as age- and sex-matched control.The frequencies of gastroesophageal reflux disease (GERD) and negative Helicobacter pylori infection without atrophy were significantly higher in gastric cardia cancers, but there was no difference in the frequency of obesity. The frequency of early gastric cancers was 40.0%, which was significantly lower than that of noncardia cancer. The rate of recurrence, disease-free survival, and overall survival duration were significantly lower in gastric cardia cancers (P < .01), even though there was no significant difference in the rate of curative resection (R0). In terms of the etiologic factors, there were no differences of disease prognosis, regardless of the presence of GERD, obesity, and H pylori infection with associated gastritis.Gastric cardia cancer showed distinct clinical characteristics and a negative prognostic impact compared with gastric noncardia cancer.

Comparison of totally laparoscopic and open approach in total gastrectomy with D2 lymphadenectomy - systematic review and meta-analysis

Introduction

Gastric cancer is a worldwide health concern, being one of the five most common malignant neoplasms worldwide. Currently, an open approach is the gold standard for surgical treatment. Incorporation of laparoscopy as a method of choice for gastric resections remains controversial because of limited evidence of eligibility. To date, there are no high-quality randomized quality trials on totally laparoscopic D2 total gastrectomies.

Aim

The aim of this study was to assess currently available literature and provide meta-analysis on acquired data regarding short-term outcomes with a subgroup analysis of western and eastern studies.

Materials and methods

We performed a systematic review and meta-analysis according to the PRISMA guidelines. The primary outcomes of interest were morbidity and short-term complications.

Results

An initial reference search yielded 3,073 articles. Finally, we chose eight studies covering 1,582 patients that we included in the quantitative analysis. We did not find statistical differences regarding operative time, anastomotic leakage, surgical site infection, cardiac complications, pulmonary complications, or number of harvested lymph nodes. We found significant differences regarding length of hospital stay and morbidity in the Asian population.

Conclusion

This systematic review indicates that a laparoscopic approach for D2 total gastrectomy does not increase morbidity. Furthermore, it allows for a shorter hospital stay. However, more randomized controlled trials are required to fully assess this approach because available data are of limited quality.

Short-term outcomes in minimally invasive versus open gastrectomy: the differences between East and West. A systematic review of the literature

OBJECTIVE

Minimally invasive surgical techniques for gastric cancer are gaining more interest worldwide. Several Asian studies have proven the benefits of minimally invasive techniques over the open techniques. Nevertheless, implementation of this technique in Western countries is gradual. The aim of this systematic review is to give insight in the differences in outcomes and patient characteristics in Asian countries in comparison to Western countries.

METHODOLOGY

An extensive systematic search was conducted using the Medline, Embase, and Cochrane databases. Analysis of the outcomes was performed regarding operative results, postoperative recovery, complications, mortality, lymph node yield, radicality of the resected specimen, and survival. A total of 12 Asian and 8 Western studies were included.

RESULTS

Minimally invasive gastrectomy shows faster postoperative recovery, fewer complications, and similar outcomes regarding mortality in both the Eastern and Western studies. However, patient characteristics such as age and BMI differ between these populations. Comparison of overall outcomes in minimally invasive and open procedures between East and West showed differences in complications, mortality, and number of resected lymph nodes in favor of the Asian population.

CONCLUSION

Improved outcomes are observed following minimally invasive gastrectomy in comparison to open procedures in both Western and Asian studies. There are differences in patient characteristics between the Western and Asian populations. Overall outcomes seem to be in favor of the Asian population. These differences may fade with centralization of care for gastric cancer patients in the West and increasing surgical experience.

Comparisons of short-term and survival outcomes of laparoscopy-assisted versus open total gastrectomy for gastric cancer patients

OBJECTIVES

The safety and surgical oncology of laparoscopy-assisted total gastrectomy (LATG) remain inconclusive and challenging. This study aimed to compare the short-term and long-term outcomes between LATG and open total gastrectomy (OTG) procedures.

RESULTS

In the all-included analyses, there were 69 patients in the LATG group and 268 in the OTG group. LATG was as safe as OTG without increasing postoperative morbidity and mortality. Stage imbalance might introduce differences in the numbers of harvested lymph nodes in LATG (34.4 ± 12.0) and OTG (40.9 ± 16.9), whereas 95.7% of patients underwent D2/D2+ dissection during the LATG procedure. After a median 31 months of follow-up, the overall survival outcomes were comparable between the LATG and OTG procedures (HR = 1.16, 95% CI 0.68-1.97). Sensitivity analysis found comparable node retrieval and stage-specific or treatment-specific overall survival.

MATERIALS AND METHODS

A retrospective case-control study was conducted among gastric cancer patients who underwent either LATG or OTG with curative intention between June 2006 and December 2015. Data retrieval was based on the Surgical Gastric Cancer Patient Registry in the West China Hospital. The primary outcome was overall survival. The secondary outcomes were postoperative complication incidence and severity, operation duration, blood loss, number of harvested lymph nodes, and postoperative hospital stay. Matched pairwise case-control comparisons were performed as a sensitivity analysis.

CONCLUSIONS

LATG by experienced surgeons possibly has comparable short-term surgical outcomes and long-term survival outcomes compared with OTG for gastric cancer patients. However, high-quality RCTs are necessary before confirmative judgment and recommendation as an optional treatment in general practice.

DO PROXIMAL AND DISTAL GASTRIC TUMOURS BEHAVE DIFFERENTLY?

Background:

Although the incidence of gastric (adenocarcinoma) cancer has been decreasing over time, it is still one of the most common malignancies worldwide, and proximal tumours tend to have a worse prognosis.

Aim:

To compare surgical outcomes and prognosis between proximal - excluding tumours of the cardia - and distal gastric cancer.

Methods:

Out of 293 cases reviewed - 209 with distal and 69 with proximal gastric cancer - were compared for clinical and pathological features, stage, surgical outcome, mortality and survival.

Results:

Statistically, there was no significant difference between patients in both groups regarding mortality (p=0.661), adjuvant chemotherapy (p 0.661), and radiation (p=1.000). However, there was significant difference in the degree of lymph node dissection employed (p=0.002) and the number of positive lymph nodes resected (p=0.038) between the two groups. The odds of death at five years for patients who had a D0 dissection was three times greater (odds ratio 2.78; (95%CI 1.33-5.82) than that for patients who had a D2 dissection, while for patients who had a D1 dissection the odds ratio was only 1.41 (95%CI 0.71-2.83) compared to D2-dissected patients.

Conclusion:

Although no significant differences were found between proximal and distal gastric cancer, the increased risk of death in D0- and D1-dissected patients clearly suggests an important role of radical D2 lymph node dissection in survival.

Minimally invasive surgery for gastric cancer in Brazil: current status and perspectives-a report from the Brazilian Laparoscopic Oncologic Gastrectomy Group (BLOGG)

The minimally invasive surgery for gastric cancer in Brazil has begun about two years after the first laparoscopic gastrectomy (LG) performed by Kitano in Japan, in 1991. Although the report of first surgeries shows the year of 1993, there was no dissemination of the technique until the years 2010. At that time with the improvement of optical devices, laparoscopic instruments and with the publications coming from Asia, several Brazilian surgeons felt encouraged to go to Korea and Japan to learn the standardization of the LG. After that there was a significant increase in that type of surgery, especially after the IRCAD opened a branch in Brazil. The growing interest for the subject led some services to begin their own experience with the LG and, since the beginning, the results were similar with those found in the open surgery. Nevertheless, there were some differences with the papers published initially in Japan and Korea. In those countries, the surgeries were laparoscopic assisted, meaning that, in the majority of cases, the anastomoses were done through a mini-incision in the end of the procedure. In Brazil since the beginning it was performed completely through laparoscopic approach due to the skills acquired by Brazilian surgeons in bariatric surgeries. Another difference was the stage. While in the east the majority of cases were done in T1 patients, in Brazil, probably due to the lack of early cases, the surgeries were done also in advanced cases. The initial experience of Zilberstein et al. revealed low rates of morbidity without mortality. Comparing laparoscopic and open surgery, the group from Barretos/IRCAD showed shorter surgical time (216×255 minutes), earlier oral or enteral feeding and earlier hospital discharge, with a smaller number of harvested lymph nodes (28 in laparoscopic against 33 in open surgery). There was no significant difference regarding morbidity, mortality and reoperation rate. In the first efforts to publish a multicentric study the Brazilian Gastric Cancer Association (BGCA) collected data from three institutions analyzing 148 patients operated from 2006 to 2016. There were 98 subtotal, 48 total and 2 proximal gastrectomies. The anastomoses were totally laparoscopic in 105, laparoscopic assisted in 21, cervical in 2, and 20 open (after conversion). The reconstruction methods were: 142 Roux-en-Y, two Billroth I, and three other types. The conversion rate was 13.5% (20/148). The D2 dissection was performed in 139 patients. The mean number of harvested lymph nodes was 34.4. If we take only the D2 cases the mean number was 39.5. The morbidity rate was 22.3%. The mortality was 2.7%. The stages were: IA-59, IB-14, IIA-11, IIB-15, IIIA-9, IIIB-19, IIIC-11 and stage IV-three cases. Four patients died from the disease and 10 are alive with disease. The participating services have already begun the robotic gastrectomy with satisfactory results. The intention of this group is to begin now a prospective multicentric study to confirm the data already obtained with the retrospective studies.

DETECTION OF OCCULT LYMPH NODE TUMOR CELLS IN NODE-NEGATIVE GASTRIC CANCER PATIENTS

BACKGROUND

The presence of lymph nodes metastasis is one of the most important prognostic indicators in gastric cancer. The micrometastases have been studied as prognostic factor in gastric cancer, which are related to decrease overall survival and increased risk of recurrence. However, their identification is limited by conventional methodology, since they can be overlooked after routine staining.

AIM

To investigate the presence of occult tumor cells using cytokeratin (CK) AE1/AE3 immunostaining in gastric cancer patients histologically lymph node negative (pN0) by H&E.

METHODS

Forty patients (T1-T4N0) submitted to a potentially curative gastrectomy with D2 lymphadenectomy were evaluated. The results for metastases, micrometastases and isolated tumor cells were also associated to clinicopathological characteristics and their impact on stage grouping. Tumor deposits within lymph nodes were defined according to the tumor-node-metastases guidelines (7th TNM).

RESULTS

A total of 1439 lymph nodes were obtained (~36 per patient). Tumor cells were detected by immunohistochemistry in 24 lymph nodes from 12 patients (30%). Neoplasic cells were detected as a single or cluster tumor cells. Tumor (p=0.002), venous (p=0.016), lymphatic (p=0.006) and perineural invasions (p=0.04), as well as peritumoral lymphocytic response (p=0.012) were correlated to CK-positive immunostaining tumor cells in originally negative lymph nodes by H&E. The histologic stage of two patients was upstaged from stage IB to stage IIA. Four of the 28 CK-negative patients (14.3%) and three among 12 CK-positive patients (25%) had disease recurrence (p=0.65).

CONCLUSION

The CK-immunostaining is an effective method for detecting occult tumor cells in lymph nodes and may be recommended to precisely determine tumor stage. It may be useful as supplement to H&E routine to provide better pathological staging.

Postoperative Complications of Laparoscopic Total Gastrectomy versus Open Total Gastrectomy for Gastric Cancer in a Meta-Analysis of High-Quality Case-Controlled Studies

Background. Some meta-analyses of case-controlled studies (CCSs) have shown that laparoscopic or laparoscopy-assisted total gastrectomy (LTG) had some short-term advantages over open total gastrectomy (OTG). However, postoperative complications differed somewhat among the meta-analyses, and some CCSs included in the meta-analyses had mismatched factors between LTG and OTG. Methods. CCSs comparing postoperative complications between LTG and OTG were identified in PubMed and Embase. Studies matched for patients' status, tumor stage, and the extents of lymph-node dissection were included. Outcomes of interest, such as anastomotic, other intra-abdominal, wound, and pulmonary complications, were evaluated in a meta-analysis performed using Review Manager version 5.3 software. Result. This meta-analysis included a total of 2,560 patients (LTG, 1,073 patients; OTG, 1,487 patients) from 15 CCSs. Wound complications were significantly less frequent in LTG than in OTG (n = 2,430; odds ratio [OR] 0.30, 95% confidence interval [CI] 0.29-0.85, P = 0.01, I2 = 0%, and OR 0.46, 95% CI 0.17-0.52, P < 0.0001, I2 = 0%). However, the incidence of anastomotic complications was slightly but not significantly higher in LTG than in OTG (n = 2,560; OR 1.44, 95% CI 0.96-2.16, P = 0.08, I2 = 0%). Conclusion. LTG was associated with a lower incidence of wound-related postoperative complications than was OTG in this meta-analysis of CCSs; however, some concern remains about anastomotic problems associated with LTG.

MINIMALLY INVASIVE SURGERY FOR GASTRIC CANCER: TIME TO CHANGE THE PARADIGM

INTRODUCTION

Minimally invasive surgery widely used to treat benign disorders of the digestive system, has become the focus of intense study in recent years in the field of surgical oncology. Since then, the experience with this kind of approach has grown, aiming to provide the same oncological outcomes and survival to conventional surgery. Regarding gastric cancer, surgery is still considered the only curative treatment, considering the extent of resection and lymphadenectomy performed. Conventional surgery remains the main modality performed worldwide. Notwithstanding, the role of the minimally invasive access is yet to be clarified.

OBJECTIVE

To evaluate and summarize the current status of minimally invasive resection of gastric cancer.

METHODS

A literature review was performed using Medline/PubMed, Cochrane Library and SciELO with the following headings: gastric cancer, minimally invasive surgery, robotic gastrectomy, laparoscopic gastrectomy, stomach cancer. The language used for the research was English.

RESULTS

28 articles were considered, including randomized controlled trials, meta-analyzes, prospective and retrospective cohort studies.

CONCLUSION

Minimally invasive gastrectomy may be considered as a technical option in the treatment of early gastric cancer. As for advanced cancer, recent studies have demonstrated the safety and feasibility of the laparoscopic approach. Robotic gastrectomy will probably improve outcomes obtained with laparoscopy. However, high cost is still a barrier to its use on a large scale.