Surgical outcomes and learning curve analysis of robotic gastrectomy for gastric cancer: Multidimensional analysis compared with three‑dimensional high‑definition laparoscopic gastrectomy

Feasibility of articulating laparoscopic instruments in laparoscopic gastrectomy using propensity score matching

Advancements in minimally invasive surgery has led to the development of several surgical instruments, including the ArtiSential®. This new instrument provides a greater range of motion and improved dexterity to laparoscopic procedures, making it an alternative option to traditional straight instruments, and the Da Vinci robot system. The purpose of this study is to compare the postoperative outcomes of a prospective cohort of patients who underwent laparoscopic gastrectomy using articulating instruments with those of a historical cohort of patients who underwent the same procedure using straight instruments. The study was designed as a prospective observational cohort study matched to a retrospective historical cohort using propensity score matching. The primary outcome was the rate of early complications within 90 days of surgery. Other outcomes included the operation time, estimated blood loss, time to first flatus, time to first soft fluid diet, hospital stay, and mortality. After propensity score matching, 41 patients were enrolled in both groups. The mean age was 62.4 ± 12.3 years in the conventional group and 63.5 ± 9.6 years in the artisential group (p = 0.647). Mean operative time was significantly shorter in the artisential group compared to the conventional group (136.1 min vs. 163.9 min, p = 0.032). The time to first soft fluid diet was also significantly shorter in the artisential group (2.2 days vs. 2.8 days, p = 0.030), but there was no significant difference in the time to first flatus and overall hospital stay. The incidence of early complications was lower in the artisential group, but the difference was not significant (24.4% vs 7.3%, p = 0.070). There was no mortality in either group. The use of articulating instruments for laparoscopic gastrectomy did not increase postoperative morbidity compared to straight laparoscopic instruments. The use of articulating instruments may be associated with faster bowel recovery and less early complications.

Robotic versus laparoscopic gastrectomy for gastric cancer in patients with obesity: systematic review and meta-analysis

Introduction

The number of overweight patients with gastric cancer (GC) is increasing, and no previous study has compared laparoscopic gastrectomy (LG) and robotic gastrectomy (RG) in obese patients with GC. To investigate the perioperative and oncologic outcomes of RG and LG in obese GC patients, we performed a meta-analysis of propensity matched scores and retrospective studies to compare the perioperative parameters, oncologic findings, and short-term postoperative outcomes between the two groups.

Methods

This study was performed according to the PRISMA guidelines. A search was performed on PubMed, Web of Science, EMBASE, and Cochrane Central Register to identify eligible propensity matched scores and retrospective studies conducted and published before December 2022. Data on perioperative and oncological outcomes were included in the meta-analysis.

Results

Overall, we identified 1 propensity score match study and 5 randomized control trials of RG and LG, enrolling a total of 718 patients (197 and 521 patients received RG and LG, respectively). No significant differences were observed between the two groups in terms of complications, bleeding, or lymph node dissection. Of note, RG had a longer procedure time (P = 0.03), earlier oral intake (P = 0.0010), shorter hospital stay (P = 0.0002), and shorter time to defecation (P < 0.00001).

Conclusions

This meta-analysis concluded that patients in the RG group had shorter hospital stays, earlier postoperative feeding, and earlier postoperative ventilation; however, no differences were found in blood loss, number of lymph nodes removed, or overall complications. RG is an effective, safe, and promising treatment for obese patients with GC, compensating for the shortcomings of laparoscopy and allowing for less trauma and faster recovery.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022298967.

Cumulative sum analysis of the learning curve of ptosis surgery: External levator advancement versus Müller's muscle-conjunctival resection

Purpose

Even though it is stated that external levator advancement (ELA) has a much longer learning curve than Müller muscle-conjunctival resection (MMCR) in the treatment of aponeurotic ptosis, there is no study in the literature regarding the learning curves of these two surgical techniques. We aimed to objectively determine the length of the learning curves of ELA and MMCR using cumulative sum (CUSUM) analysis.

Methods

The first 30 unilateral ELA and the first 30 unilateral MMCR consecutively performed by a single surgeon were retrospectively reviewed. The CUSUM method was used to analyze the learning curves of ELA and MMCR based on operation times of consecutive surgeries and the clinical outcomes were compared.

Results

CUSUM analyses revealed that the operation time stabilized after around 11 ELA surgeries and 12 MMCR surgeries and R² value for ELA and MMCR were 0.93 and 0.91, respectively. There was no significant difference in these stratified analyses. Mean operation time was 45.7 minutes in the ELA group and 34.1 minutes in the MMCR group (p = 0.002). Total number of intraoperative complications was 37 in the ELA group and 16 in the MMCR group (p = 0.015). Symmetry success rate was significantly higher (p < 0.0001) and reoperation rate was significantly lower in the MMCR group (p = 0.045).

Conclusions

Even though ELA is more challenging than MMCR, comparable learning curves indicate that surgeons in training need to be encouraged to perform both techniques. The challenges and obstacles that the surgeons in training face in these two techniques need to be analyzed in detail.

Comparison of Operative Outcomes Among Laparoscopic, 3D-Laparoscopic, and Robotic Gastrectomy for Distal Gastric Cancer

Objective

Minimally invasive surgery has become popular in the treatment of gastric cancer.

Background

Few reports have compared operative outcomes among laparoscopic, 3-dimensional (3D)-laparoscopic, and robotic gastrectomy for distal gastric cancer.

Methods

Between August 2011 and June 2020, a total of 245 patients underwent laparoscopic (n = 129), 3D-laparoscopic (n = 55), or robotic (n = 61) gastrectomy for distal gastric cancer; the clinicopathologic characteristics and operative outcomes were compared among groups.

Results

Compared with the laparoscopic group, the 3D-laparoscopic and robotic groups were associated with more D2 lymphadenectomy, higher medical costs, and a longer operative time, whereas the number of retrieved lymph nodes and surgical complications were similar among the 3 groups. For patients receiving D2 lymphadenectomy, the robotic group was associated with higher medical costs and longer operative time than the other 2 groups; patients with high body mass index (high BMI) had a longer operative time than patients with low BMI in the laparoscopic group, which was not significantly different between patients with low or high BMI in both the 3D-laparoscopic and robotic groups. For patients with low BMI, the medical costs were higher and the operative time was longer in the robotic group than the other 2 groups. For patients with high BMI, the robotic group was associated with higher medical costs, and longer operative time and postoperative hospital stay than the other 2 groups.

Conclusions

3D-laparoscopic gastrectomy was associated with affordable medical costs, comparable lymphadenectomy, and similar surgical outcomes compared with robotic gastrectomy.

Incidence and risk factors of postoperative complications after robotic gastrectomy for gastric cancer: an analysis of 817 cases based on 10-year experience in a large-scale center

BACKGROUND

In this study, we investigated the incidence and risk factors for postoperative complications after robotic gastrectomy (RG) in patients with gastric cancer.

METHODS

A total of 817 patients who underwent RG for gastric cancer between March 2010 and August 2019 were analyzed retrospectively. Postoperative complications were categorized according to the Clavien-Dindo classification, and possible risk factors were evaluated.

RESULTS

Among 817 patients who underwent RG, overall, severe, local and systemic complication rates were 13.8, 4.2, 7.0 and 6.9%, respectively. Multivariable analysis revealed that an age of 70 years or older (P < 0.001) and multiorgan resection (P = 0.031) were independent risk factors for the occurrence of overall complications. Multivariable analysis showed that an age of 70 years or older (P = 0.005) and surgeons' experience ≤ 25 cases (P = 0.004) were independent risk factors for severe complications. Regarding local complications, an age of 70 years or older (P < 0.001), multiorgan resection (P = 0.010) and surgeons' experience ≤ 25 cases (P = 0.005) were identified as independent risk factors. An age of 70 years or older (P < 0.001), a BMI of 25 or higher (P = 0.045) and the presence of comorbidity (P = 0.029) were identified as independent risk factors for systemic complications.

CONCLUSIONS

The present study demonstrated that RG is a safe and feasible procedure for the treatment of gastric cancer, and it has an acceptable postoperative morbidity. Elderly patients and insufficient surgeon experience were two major risk factors for the occurrence of complications following RG. We suggest that surgeons choose patients in good condition during their RG learning phase to reduce learning-associated morbidity.