Comparison of Surgical Outcomes between Robotic and Laparoscopic Gastrectomy for Gastric Cancer: The Learning Curve of Robotic Surgery

Robotic spleen‑preserving suprapancreatic and splenic hilar lymph node dissection using the preemptive retropancreatic approach in total gastrectomy for gastric cancer

Advanced gastric cancer that has not invaded the greater curvature is a good indication for total gastrectomy (TG) with spleen-preserving suprapancreatic and splenic hilar lymph node dissection (LND). However, the suprapancreatic and splenic hilar LND increases the area of dissection of the pancreas, and prolonged pressure drainage of the pancreas is required to maintain a clear operative view. This can lead to an increased risk of postoperative pancreatic complications. To report the efficacy of our novel preemptive retropancreatic approach (PRA) for the suprapancreatic and splenic hilar LND in robotic TG (RTG). We report our experience with nine patients with gastric cancer who underwent spleen-preserving splenic hilar LND using PRA during RTG at Hokkaido University from October 2018 to November 2021. The PRA involves initial dissection of the left side of the retropancreatic space, followed by the release of the adherence between the retroperitoneum surface and the pancreas (fusion fascia), which provides a good operative field and prevents contact with the pancreas during the suprapancreatic and splenic hilar LND in RTG. The median operating time was 488 min (254-564 min). The median intraoperative bleeding was 55 mL (0-115 mL). One patient had postoperative complications (above grade II of the Clavien-Dindo classification), but there were no postoperative pancreatic complications. The spleen-preserving suprapancreatic and splenic hilar LND using PRA could help to reduce the postoperative pancreatic complications associated with RTG.Trial registration number and date of registration The Hokkaido University Hospital institutional review board approved the data collection and analysis. The trial registration number and date of registration are No. 021-0022 and July 26, retrospectively registered.

Establishing the Learning Curve of Laparoscopic and Robotic Distal Gastrectomy: a Systematic Review and Meta-Regression Analysis

BACKGROUND

Minimally invasive distal gastrectomy (MIDG) is non-inferior compared with open distal gastrectomy for gastric cancer. However, MIDG bears a learning curve (LC). This study aims to evaluate the number of cases required to surmount the LC (i.e. NLC) in MIDG.

METHODS

PubMed, Embase, Scopus, and the Cochrane Library were systematically searched from inception to August 2022 for studies which reported NLC in MIDG. NLC on reduced-port/single-port MIDG only were separately analysed. Poisson mean (95% confidence interval (CI)) was used to determine NLC. Negative binomial regression was used to compare NLC between laparoscopic distal gastrectomy (LDG) and robotic distal gastrectomy (RDG).

RESULTS

A total of 45 articles with 71 data sets (LDG n=47, RDG n=24) were analysed. There were 7776 patients in total (LDG n=5516, RDG n=2260). Majority of studies were conducted in East Asia (n=68/71). Majority (76.1%) of data sets used non-arbitrary methods of analyses. The overall NLC for RDG was significantly lower compared to LDG (RDG 22.4 (95% CI: 20.4-24.5); LDG 46.7 (95% CI: 44.1-49.4); incidence rate ratio 0.48, p<0.001). The median number of laparoscopic gastrectomy (LG) cases prior was 0 (interquartile range (IQR) 0-105) for LDG and 159 (IQR 101-305.3) for RDG. Meta-regression analysis did not show a significant impact prior experience in LG, extent of lymphadenectomy and intracorporeal vs extracorporeal anastomosis had on overall NLC for LDG and RDG.

CONCLUSION

NLC for RDG is shorter compared to LDG, but this may be due to prior experience in LG and ergonomic advantages of RDG.

Advantages of robotic gastrectomy for overweight patients with gastric cancer: a comparison study of robotic gastrectomy and conventional laparoscopic gastrectomy

PURPOSE

A high body mass index (BMI) generally increases the risk of postoperative complications because of the intraperitoneal adipose tissue. Robotic gastrectomy (RG) decreases the surgical difficulty of conventional laparoscopic gastrectomy (LG) for these patients. We conducted the present study to identify the advantages of RG over LG for overweight patients.

METHODS

We reviewed clinical data on patients who underwent either LG or RG at the National Cancer Center Hospital East between January, 2014 and May, 2022.

RESULTS

The 1298 patients eligible patients were divided into a non-overweight cohort (n = 996) (LG, n = 818; RG, n = 178) and an overweight cohort (n = 302) (LG, n = 250; RG, n = 52) according to a BMI cut-off of 25 kg/m2. In the overweight cohort, the RG group had a lower incidence of grade ≥ III postoperative complications (0.0 vs. 8.8%, p = 0.01) and grade ≥ II postoperative complications (11.5 vs. 22.0%, p = 0.12) than the LG group. Multivariate analysis identified that RG was significantly associated with a lower incidence of grade ≥ II postoperative complications in the overweight cohort (odds ratio, 0.33; 95% confidence interval, 0.12-0.87; p = 0.02).

CONCLUSIONS

RG may reduce the risk of postoperative complications, compared with conventional LG, in overweight patients.

Effects of the learning curve on operative time and lymph node harvesting during robotic gastrectomy

BACKGROUND

Gastric cancer is the fifth most frequent cancer globally. The introduction of minimally invasive surgery for gastric cancer aimed at reducing post-operative morbidity and hospital length of stay. Although the role of laparoscopic gastrectomy has been established, robotic gastric surgery has only recently gained popularity. The purpose of this study was to evaluate, with a multidimensional analysis, the learning curve of a single surgeon with extensive experience in laparoscopic gastrectomy.

METHODS

We prospectively collected data from 104 gastric cancer patients who underwent surgery with a robotic approach from June 2015 to June 2019 by a single surgeon. We performed 21 total gastrectomies (TGs) and 83 subtotal gastrectomies (STGs). A D2 lymphadenectomy was performed in all the patients. Proximal and distal resection margins were tumoour-free in all patients. There were no intraoperative complications, and no conversions occurred.

RESULTS

The plateau of the learning curve based on harvesting lymph nodes and operative time was not reached for TG. The learning curve of operative time for STG could be divided into three different phases: an early or learning phase from 1 to 27 cases, an intermediate or proficiency phase from 28 to 48 cases, and a late or mastery phase from 49 to 83 cases. The learning curve for harvesting lymph nodes was achieved after 41 cases in the STG group.

CONCLUSION

This study shows that robotic gastrectomy is a complex procedure with a significant multiphasic learning curve. Nevertheless, the robotic learning curve seems to be more rapid than that of conventional laparoscopy. Most importantly, our results suggest that the robotic technique can provide oncological adequacy in terms of lymph node harvesting even in the very first phase of the learning curve.

Minimally Invasive and Open Gastrectomy for Gastric Cancer: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

BACKGROUND AND OBJECTIVES

Optimal surgical management for gastric cancer remains controversial. We aimed to perform a network meta-analysis (NMA) of randomized clinical trials (RCTs) comparing outcomes after open gastrectomy (OG), laparoscopic-assisted gastrectomy (LAG), and robotic gastrectomy (RG) for gastric cancer.

METHODS

A systematic search of electronic databases was undertaken. An NMA was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. Statistical analysis was performed using R and Shiny.

RESULTS

Twenty-two RCTs including 6890 patients were included. Overall, 49.6% of patients underwent LAG (3420/6890), 46.6% underwent OG (3212/6890), and 3.7% underwent RG (258/6890). At NMA, there was a no significant difference in recurrence rates following LAG (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.77-1.49) compared with OG. Similarly, overall survival (OS) outcomes were identical following OG and LAG (OS: OG, 87.0% [1652/1898] vs. LAG: OG, 87.0% [1650/1896]), with no differences in OS in meta-analysis (OR 1.02, 95% CI 0.77-1.52). Importantly, patients undergoing LAG experienced reduced intraoperative blood loss, surgical incisions, distance from proximal margins, postoperative hospital stays, and morbidity post-resection.

CONCLUSIONS

LAG was associated with non-inferior oncological and surgical outcomes compared with OG. Surgical outcomes following LAG and RG superseded OG, with similar outcomes observed for both LAG and RG. Given these findings, minimally invasive approaches should be considered for the resection of local gastric cancer, once surgeon and institutional expertise allows.

Short- and long-term outcomes of laparoscopic or robotic radical gastrectomy based on preoperative perigastric artery CTA surgical decision-making: a high-volume center retrospective study with propensity score matching

BACKGROUND

Some studies have demonstrated the short-term recovery course for patients who underwent laparoscopic gastrectomy according to preoperative computed tomography angiography (CTA) assessment. However, reports of the long-term oncological outcomes are still limited.

METHODS

The data of 988 consecutive patients who underwent laparoscopic or robotic radical gastrectomy between January 2014 and September 2018 were analyzed retrospectively at our center, and propensity score matching was used to eliminate bias. Study cohorts were divided into the CTA group (n = 498) and the non-CTA group (n = 490) depending on whether preoperative CTA was available. The primary and secondary endpoints were the 3-year overall survival (OS) and disease-free survival (DFS) rates and the intraoperative course and short-term outcomes, respectively.

RESULTS

431 patients were included in each group after PSM. Compared with the non-CTA group, the CTA group had more harvested lymph nodes and less operative time, blood loss, intraoperative vascular injury and total cost, especially in the subgroup analysis with BMI ≥ 25 kg/m2 patients. There was no difference in the 3 year OS and DFS between the CTA group and the non-CTA group. When further stratified by BMI < 25 or ≥ 25 kg/m2, the 3-year OS and DFS were significantly higher in the CTA group than in the non-CTA group in terms of BMI ≥ 25 kg/m2.

CONCLUSIONS

Laparoscopic or robotic radical gastrectomy based on preoperative perigastric artery CTA surgical decision-making has the possibility of improving short-term outcomes. However, there is no difference in the long-term prognosis, except for a subgroup of patients with BMI ≥ 25 kg/m2.

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.

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.

The comparison of short-term outcomes between robotic and laparoscopic radical distal gastrectomy

PURPOSE

The study's objectives were to compare the short-term outcomes of robotic radical distal gastrectomy (RDG) with laparoscopic radical distal gastrectomy (LDG) for patients with gastric cancer and investigate the learning curve of RDG.

METHODS

The cumulative sum (CUSUM) method was used to retrospectively analyze consecutive gastric cancer patients undergoing RDG between January 2019 and October 2021. The duration of surgery, clinical-pathological characteristics, and short-term outcomes were evaluated according to the two phases of the learning curve (learning period versus mastery period). We also compared the clinical-pathological characteristics and short-term outcomes between cases in the mastery period and LDG.

RESULTS

Data from 290 patients were included in this analysis, 135 RDG and 155 LDG cases. The learning period was 20 cases. There were no significant differences in clinical-pathological characteristics between the learning period and mastery period. Compared with the learning period, the mastery period had a significant reduction in total operation time, docking time, pure operation time, and estimated blood loss, and a significant increase in hospital costs (P=0.000, 0.000, 0.000, 0.003, and 0.026, respectively). Compared with LDG, robotic cases in mastery period had a longer operative time, shorter first postoperative flatus time, and more hospital costs (P=0.000, 0.005, and 0.000, respectively).

CONCLUSIONS

RGD may fasten to recover gastrointestinal function faster after the operation, can be mastered easily after a reasonable number of cases, and was associated with safe and satisfactory short-term outcomes before and after the learning curve.

Evaluation of surgical complexity by automated surgical process recognition in robotic distal gastrectomy using artificial intelligence

BACKGROUND

Although radical gastrectomy with lymph node dissection is the standard treatment for gastric cancer, the complication rate remains high. Thus, estimation of surgical complexity is required for safety. We aim to investigate the association between the surgical process and complexity, such as a risk of complications in robotic distal gastrectomy (RDG), to establish an artificial intelligence (AI)-based automated surgical phase recognition by analyzing robotic surgical videos, and to investigate the predictability of surgical complexity by AI.

METHOD

This study assessed clinical data and robotic surgical videos for 56 patients who underwent RDG for gastric cancer. We investigated (1) the relationship between surgical complexity and perioperative factors (patient characteristics, surgical process); (2) AI training for automated phase recognition and model performance was assessed by comparing predictions to the surgeon-annotated reference; (3) AI model predictability for surgical complexity was calculated by the area under the curve.

RESULT

Surgical complexity score comprised extended total surgical duration, bleeding, and complications and was strongly associated with the intraoperative surgical process, especially in the beginning phases (area under the curve 0.913). We established an AI model that can recognize surgical phases from video with 87% accuracy; AI can determine intraoperative surgical complexity by calculating the duration of beginning phases from phases 1-3 (area under the curve 0.859).

CONCLUSION

Surgical complexity, as a surrogate of short-term outcomes, can be predicted by the surgical process, especially in the extended duration of beginning phases. Surgical complexity can also be evaluated with automation using our artificial intelligence-based model.

Surgical and short-term outcomes in robotic and laparoscopic distal gastrectomy for gastric cancer with enhanced recovery after surgery protocol: A propensity score matching analysis

OBJECTIVE

This study aims to evaluate the short-term surgical outcomes of laparoscopy-assisted distal gastrectomy (LADG) and robot-assisted distal gastrectomy (RADG) for gastric cancer (GC) with enhanced recovery after surgery (ERAS) protocols.

METHODS

We reviewed the medical records of 202 patients undergoing radical distal gastrectomy; among them, 67 cases were assisted through RADG, while 135 cases were assisted through LADG along with ERAS. We retrospectively collected the medical records in succession from a database (January 2016-March 2019). We adopted propensity score matching to compare surgical and short-term outcomes of both groups.

RESULTS

After the successful examination of 134 cases, including 67 receiving RADG and 67 undergoing LADG, the operative times were noted as 5.78 ± 0.96 h for the RADG group and 4.47 ± 1.01 h for the LADG group (P < 0.001). The blood loss was noted as 125.52 ± 101.18 ml in the RADG group and 164.93 ± 109.32 ml in the LADG group (P < 0.05). The shorter time to first flatus was 38.82 ± 10.56 h in the RADG group and 42.88 ± 11.25 h in the LADG group (P < 0.05). In contrast, shorter days of postoperative hospital stay were 5.94 ± 1.89 days in the RADG group and 6.64 ± 1.92 days in the LADG group (P < 0.05). Also, the RADG group (84483.03 ± 9487.37) was much more costly than the LADG group (65258.13 ± 8928.33) (P < 0.001). The postoperative overall complication rates, numbers of dissected lymph nodes, visual analogue scale (VAS), and time to start a liquid diet for the RADG group and the LADG group were similar.

CONCLUSIONS

In this research, we concluded that RADG provides surgical benefits and short-term outcomes compared to LADG for GC with ERAS.

Postoperative outcomes in robotic gastric resection compared with laparoscopic gastric resection in gastric cancer: A meta‐analysis and systemic review

Background

Robotic gastrectomy is a commonly used procedure for early gastric cancer and it also overcomes the limitation of laparoscopic. However, the complications of robotic gastrectomy (RG) still need to be assessed. Our study was designed to compare postoperative complications of RG with laparoscopic gastrectomy (LG).

Materials and Methods

A meta‐analysis and systemic review were prospectively collected using the PubMed, Cochrane Library, and MEDLINE database of published studies by comparing the RG and LG with gastric cancer up to December 2021. To evaluate the postoperative outcomes, odds ratios were calculated for Dichotomous data and the mean difference with 95% confidence interval (CI) was calculated for continuous data, and measured by the random‐effect model.

Results

Thirty‐two retrospective studies describing 13,585 patients (4484 RG and 9101 LG) satisfied the inclusion criteria. A statistically significant result was in blood loss (MD = −17.97, 95% Cl: −25.61 to 10.32, p < 0.001), Clavien−Dindo grade Ⅲ (odds ratio (OR) = 0.60, 95% CI: 0.48−0.76, p < 0.01), and harvested lymph node (MD = 2.62, 95% CI: 2.14−3.11, p < 0.001). There was no significant difference between robotic gastrectomy surgery (RGS) and laparoscopic gastrectomy surgery (LGS) regarding distal resection margin (DRM), proximal resection margin (PRM), conversion rate, anastomotic leakage, and overall complications.

Conclusion

Having significant outcomes in Clavien–Dindo grade III, and blood loss, harvested lymph nodes are more common in RGS, and they also help in increasing the quality of life.

Safety assessment of robotic gastrectomy and analysis of surgical learning process: a multicenter cohort study

BACKGROUND

The safety of robotic gastrectomy (RG) for gastric cancer in daily clinical settings and the process by which surgeons are introduced and taught RG remain unclear. This study aimed to evaluate the safety of RG in daily clinical practice and assess the learning process in surgeons introduced to RG.

METHODS

Patients who underwent RG for gastric cancer at Kyoto University and 12 affiliated hospitals across Japan from January 2017 to October 2019 were included. Any morbidity with a Clavien-Dindo classification grade of II or higher was evaluated. Moreover, the influence of the surgeon's accumulated RG experience on surgical outcomes and surgeon-reported postoperative fatigue were assessed.

RESULTS

A total of 336 patients were included in this study. No conversion to open or laparoscopic surgery and no in-hospital mortality were observed. Overall, 50 (14.9%) patients developed morbidity. During the study period, 14 surgeons were introduced to robotic procedures. The initial five cases had surprisingly lower incidence of morbidity compared to the following cases (odds ratio 0.29), although their operative time was longer (+ 74.2 min) and surgeon's fatigue scores were higher (+ 18.4 out of 100 in visual analog scale).

CONCLUSIONS

RG was safely performed in actual clinical settings. Although the initial case series had longer operative time and promoted greater levels of surgeon fatigue compared to subsequent cases, our results suggested that RG had been introduced safely.

Robotic Versus Laparoscopic Gastrectomy for Gastric Cancer: A Mega Meta-Analysis

Background

Laparoscopic gastrectomy and robotic gastrectomy are the most widely adopted treatment of choice for gastric cancer. To systematically assess the safety and effectiveness of robotic gastrectomy for gastric cancer, we carried out a systematic review and meta-analysis on short-term and long-term outcomes of robotic gastrectomy.

Methods

In order to find relevant studies on the efficacy and safety of robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) in the treatment of gastric cancer, numerous medical databases including PubMed, Medline, Cochrane Library, Embase, Google Scholar, and China Journal Full-text Database (CNKI) were consulted, and Chinese and English studies on the efficacy and safety of RG and LG in the treatment of gastric cancer published from 2012 to 2022 were screened according to inclusion and exclusion criteria, and a meta-analysis was conducted using RevMan 5.4 software.

Results

The meta-analysis inlcuded 48 literatures, with 20,151 gastric cancer patients, including 6,175 in the RG group and 13,976 in the LG group, respectively. Results of our meta-analysis showed that RG group had prololonged operative time (WMD = 35.72, 95% CI = 28.59–42.86, P < 0.05) (RG: mean ± SD = 258.69 min ± 32.98; LG: mean ± SD = 221.85 min ± 31.18), reduced blood loss (WMD = −21.93, 95% CI = −28.94 to −14.91, P < 0.05) (RG: mean ± SD = 105.22 ml ± 62.79; LG: mean ± SD = 127.34 ml ± 79.62), higher number of harvested lymph nodes (WMD = 2.81, 95% CI = 1.99–3.63, P < 0.05) (RG: mean ± SD = 35.88 ± 4.14; LG: mean ± SD = 32.73 ± 4.67), time to first postoperative food intake shortened (WMD = −0.20, 95% CI = −0.29 to −0.10, P < 0.05) (RG: mean ± SD = 4.5 d ± 1.94; LG: mean ± SD = 4.7 d ± 1.54), and lower length of postoperative hospital stay (WMD = −0.54, 95% CI = −0.83 to −0.24, P < 0.05) (RG: mean ± SD = 8.91 d ± 6.13; LG: mean ± SD = 9.61 d ± 7.74) in comparison to the LG group. While the other variables, for example, time to first postoperative flatus, postoperative complications, proximal and distal mar gin, R₀ resection rate, mortality rate, conversion rate, and 3-year overall survival rate were all found to be statistically similar at P > 0.05.

Conclusions

In the treatment of gastric cancer, robotic gastrectomy is a safe and effective procedure that has both short- and long-term effects. To properly evaluate the advantages of robotic surgery in gastric cancer, more randomised controlled studies with rigorous research methodologies are needed.

Enhanced recovery after surgery (ERAS) versus standard recovery for gastric cancer patients: The evidences and the issues

The significant advances that have been reached, in the last decades, in the treatment of gastric cancer, contributed to the concept of enhanced recovery after surgery (ERAS) with the aim to reduce the surgical stress, accelerate postoperative recovery, and reduce the length of hospital stay. The most important items included in the ERAS protocols are the pre-operative patient education, early mobilization and immediate oral intake from the first postoperative day. The aim of this narrative review is to focus the attention on the possible advantages of ERAS program on perioperative functional recovery outcomes after gastrectomy for gastric cancer.

Clinical efficacy and safety of robotic distal gastrectomy for gastric cancer: a systematic review and meta-analysis

BACKGROUND

Robotic distal gastrectomy (RDG) is a new technique that is rapidly gaining popularity and may help overcome the limitations of laparoscopic distal gastrectomy (LDG); however, its safety and therapeutic efficacy remain controversial. Therefore, this meta-analysis was performed to evaluate the safety and efficacy of RDG.

METHODS

We searched PubMed, EMBASE, the Cochrane Library, and Web of Science for studies that compared RDG and LDG and were published between the time of database inception and May 2021. We assessed the bias risk of the observational studies using ROBIN-I, and a random effect model was always applied.

RESULTS

The meta-analysis included 22 studies involving 5386 patients. Compared with LDG, RDG was associated with longer operating time (Mean Difference [MD] = 43.88, 95% CI = 35.17-52.60), less intraoperative blood loss (MD = - 24.84, 95% CI = - 41.26 to - 8.43), a higher number of retrieved lymph nodes (MD = 2.41, 95% CI = 0.77-4.05), shorter time to first flatus (MD = - 0.09, 95% CI = - 0.15 to - 0.03), shorter postoperative hospital stay (MD = - 0.68, 95% CI = - 1.27 to - 0.08), and lower incidence of pancreatic fistula (OR = 0.23, 95% CI = 0.07-0.79). Mean proximal and distal resection margin distances, time to start liquid and soft diets, and other complications were not significantly different between RDG and LDG groups. However, in the propensity-score-matched meta-analysis, the differences in time to first flatus and postoperative hospital stay between the two groups lost significance.

CONCLUSIONS

Based on the available evidence, RDG appears feasible and safe, shows better surgical and oncological outcomes than LDG and, comparable postoperative recovery and postoperative complication outcomes.

Effectiveness and safety of robotic gastrectomy versus laparoscopic gastrectomy for gastric cancer: a meta-analysis of 12,401 gastric cancer patients

Advanced minimally invasive techniques, such as robotic surgeries, are applied increasingly frequently around the world and are primarily used to improve the surgical outcomes of laparoscopic gastrectomy (LG). Against that background, we conducted a meta-analysis to evaluate the feasibility, safety, and effectiveness of robotic gastrectomy (RG). Studies comparing surgical outcomes between LG and RG patients were retrieved from medical databases, including RCTs and non-RCTs. The primary outcome of this study was overall survival, which was obtained by evaluating the 3-year survival rate and the 5-year survival rate. In addition, postoperative complications, mortality, length of hospital stay, and harvested lymph nodes were also assessed. We also conducted subgroup analyses stratified by resection type, body mass index, age, depth of invasion and tumour size. Ultimately, 31 articles met the criterion for our study through an attentive check of each text, including 1 RCT and 30 non-RCTs. A total of 12,401 patients were included in the analysis, with 8127 (65.5%) undergoing LG and 4274 (34.5%) undergoing RG. Compared with LG, RG was associated with fewer postoperative complications (OR 0.81; 95% CI 0.71-0.93; P = 0.002), especially pancreas-related complications (OR 0.376; 95% CI 0.156-0.911; P = 0.030), increased harvested lymph nodes (WMD 2.03; 95% CI 0.95-3.10; P < 0.001), earlier time to first flatus (WMD - 0.105 days; 95% CI - 0.207 to - 0.003; P = 0.044), longer operation time (WMD 40.192 min, 95% CI 32.07-48.31; P < 0.001), less intraoperative blood loss (WMD - 20.09 ml; 95% CI - 26.86 to - 13.32; P < 0.001), and higher expense (WMD 19,141.68 RMB; 95% CI 11,856.07-26,427.29; P < 0.001). There was no significant difference between RG and LG regarding 3-year overall survival (OR 1.030; 95% CI 0.784-1.353; P = 0.832), 5-year overall survival (OR 0.862; 95% CI 0.721-1.031; P = 0.105), conversion rate (OR 0.857; 95% CI 0.443-1.661; P = 0.648), postoperative hospital stay (WMD - 0.368 days; 95% CI - 0.75-0.013; P = 0.059), mortality (OR 1.248; 95% CI 0.514-3.209; P = 0.592), and reoperation (OR 0.855; 95% CI 0.479-1.525; P = 0.595). Our study revealed that postoperative complications, especially pancreas-related complications, occurred less often with RG than with LG. However, long-term outcomes between the two surgical techniques need to be further examined, particularly regarding the oncological adequacy of robotic gastric cancer resections.

Establishment of a Fast-Track Gastrectomy Pathway for Patients with Gastric Adenocarcinoma at a U.S. Academic Cancer Center

INTRODUCTION

Implementation of fast-track perioperative care pathways for gastric cancer patients in the U.S. has been challenging due to low disease incidence and limited safety and efficacy data. Our institution recently implemented such a pathway for gastric cancer patients undergoing gastrectomy, and we sought to study its effects.

METHODS

We analyzed data from consecutive patients who underwent gastrectomy for gastric adenocarcinoma from January 2014 to August 2020. Patients who had surgery for recurrence, urgent surgery for obstruction, bleeding, or perforation, or an intrathoracic anastomosis were excluded. The primary predictor was whether the patient had surgery before or after implementation of a perioperative fast-track gastrectomy pathway in July 2018, and the primary outcome was length of stay.

RESULTS

One hundred sixty patients were identified, 109 pre-pathway implementation and 51 post-pathway implementation. Following pathway implementation, length of stay was significantly shorter (median 6 days versus 9 days, p < 0.001), and there was no significant difference in 30-day complication rates (29% pre versus 24% post, P = 0.56) or readmission rates (18% pre versus 16% post, P = 0.85). Using linear segmented regression analysis adjusting for age, body mass index, tumor stage (early versus late), type of surgery (distal/subtotal versus total gastrectomy), and approach (open versus minimally invasive), pathway implementation was found to be associated with a 31% decreased length of stay (effect size 0.69, 95% confidence interval 0.49 - 0.98, P = 0.04).

CONCLUSIONS

Fast-track gastrectomy care pathways are safe and feasible for U.S. gastric cancer patients undergoing gastrectomy and are associated with decreased length of stay.

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

Textbook outcome is a composite quality measurement of short-term outcomes for evaluating complex surgical procedures. We compared textbook outcome and survival of robotic total gastrectomy (RTG) with those of laparoscopic total gastrectomy (LTG). We retrospectively reviewed 395 patients (RTG, n = 74; LTG, n = 321) who underwent curative total gastrectomy for gastric cancer via minimally invasive approaches from 2009 to 2018. We performed propensity score matched analysis to adjust for potential selection bias. Textbook outcome included a negative resection margin, no intraoperative complication, retrieved lymph nodes > 15, no severe complication, no reintervention, no unplanned intensive care unit admission, hospitalization ≤ 21 days, no readmission after discharge, and no postoperative mortality. Survival outcomes included 3-year overall and relapse-free survival rates. After matching, 74 patients in each group were selected. Textbook outcome was similar in the RTG and LTG groups (70.3% and 75.7%, respectively), although RTG required a longer operative time. The quality metric least often achieved was the presence of severe complications in both groups (77.0% in both groups). There were no differences in the 3-year overall survival rate (98.6% and 89.7%, respectively; log-rank P = 0.144) and relapse-free survival rate between the RTG and LTG groups (97.3% and 87.0%, respectively; log-rank P = 0.167). Textbook outcome and survival outcome of RTG were similar to those of LTG for gastric cancer.

Long-term Comparison of Robotic and Laparoscopic Gastrectomy for Gastric Cancer: A Propensity Score-weighted Analysis of 2084 Consecutive Patients

OBJECTIVE

To compare long-term outcomes between robotic and LG approaches using propensity score weighting based on a generalized boosted method to control for selection bias.

SUMMARY OF BACKGROUND DATA

Minimally invasive surgical approaches for GC are increasing, yet limited evidence exists for long-term outcomes of robotic gastrectomy (RG).

METHODS

Patients (n = 2084) with GC stages I-III who underwent LG or RG between 2009 and 2017 were analyzed. Generalized boosted method was used to estimate a propensity score derived from all available preoperative characteristics. Long-term outcomes were compared using the adjusted Kaplan-Meier method and the weighted Cox proportional hazards regression model.

RESULTS

After propensity score weighting, the population was balanced. Patients who underwent RG showed reduced blood loss (16 mL less, P = 0.025), sufficient lymph node harvest from the initial period, and no changes in surgical outcomes over time. With 52-month median follow-up, no difference was noted in 5-year overall survival in unweighted [91.5% in LG vs 94% in RG; hazard ratio (HR), 0.71; 95% confidence interval (CI), 0.46-1.1; P = 0.126] and weighted populations (94.2% in LG vs 93.2% in RG; HR, 0.88; 95% CI, 0.52-1.48; P = 0.636). There were no differences in 5-year recurrence-free survival (RFS), with unweighted 5-year RFS of 95.4% for LG and 95.2% for RG (HR, 0.95; 95% CI, 0.55-1.64; P = 0.845) and weighted 5-year RFS of 96.3% for LG and 95.3% for RG (HR, 1.24; 95% CI, 0.66-2.33; P = 0.498).

CONCLUSIONS

After balancing covariates, RG demonstrated reliable surgical outcomes from the beginning. Long-term survival after RG and LG for GC was similar.

Robotic gastrointestinal surgery: learning curve, educational programs and outcomes

The use of the robotic platform for gastrointestinal surgery was introduced nearly 20 years ago. However, significant growth and advancement has occurred primarily in the last decade. This is due to several advantages over traditional laparoscopic surgery allowing for more complex dissections and reconstructions. Several randomized controlled trials and retrospective reviews have demonstrated equivalent oncologic outcomes compared to open surgery with improved short-term outcomes. Unfortunately, there are currently no universally accepted or implemented training programs for robotic surgery and robotic surgery experience varies greatly. Additionally, several limitations to the robotic platform exist resulting in a distinct learning curve associated with various procedures. Therefore, implementation of robotic surgery requires a multidisciplinary team approach with commitment and investment from clinical faculty, operating room staff and hospital administrators. Additionally, there is a need for wider distribution of educational modules to train more surgeons and reduce the associated learning curve. This article will focus on the implementation of the robotic platform for surgery of the pancreas, stomach, liver, colon and rectum with an emphasis on the associated learning curve, educational platforms to develop proficiency and perioperative outcomes.

Robotic versus laparoscopic gastrectomy for gastric cancer: an umbrella review of systematic reviews and meta-analyses

An umbrella review was performed to summarize literature data and to investigate benefits and harm of robotic gastrectomy (RG) compared to laparoscopic (LG) approach. To overcome the intrinsic limitations of laparoscopy, the robotic approach is claimed to facilitate lymph-node dissection and complex reconstruction after gastrectomy, to assure oncologic safety also in advanced gastric cancer. A literature search was conducted in PubMed, Cochrane and Embase databases for all meta-analyses published up to December 2019. The search strategy was previously published in a protocol. We selected fourteen meta-analyses comparing outcomes between LG and RG with curative intent in patients with diagnosis of resectable gastric cancer. We highlight that RG has a longer operation time, inferior blood loss, reduction in hospital stay and a more rapid recovery of bowel function. In meta-analyses with statistical significance the number of nodes removed in RG is higher than LG and the distal margin of resection is higher. There is no difference in terms of total complication rate, mortality, morbidity, anastomotic leakage, anastomotic stenosis, intestinal obstruction and in conversion rate to open technique. The safety and efficacy of robotic gastrectomy are not clearly supported by strong evidence, suggesting that the outcomes reported for each surgical technique need to be interpreted with caution, in particular for the meta-analyses in which the heterogeneity is large. Certainly, robotic gastrectomy is associated with shorter time to oral intake, lesser intraoperative bleeding and longer operation time with an acceptable level of evidence. On the other hand, the data regarding other outcomes are insufficient as well as non-significant, from an evidence point of view, to draw any robust conclusion.

Is it Beneficial to Utilize an Articulating Instrument in Single-Port Laparoscopic Gastrectomy?

PURPOSE

As the number of gastric cancer survivors is increasing and their quality of life after surgery is being emphasized, single-port surgery is emerging as an alternative to conventional gastrectomy. A novel multi-degree-of-freedom (DOF) articulating device, the ArtiSential® device (LivsMed, Seongnam, Korea), was designed to allow more intuitive and meticulous control for surgeons facing ergonomic difficulties with conventional tools. In this study, we evaluated the feasibility of this new device during single-port laparoscopic distal gastrectomy (SP-LDG) for early gastric cancer (EGC) patients.

MATERIALS AND METHODS

Consecutive patients diagnosed with EGC who underwent SP-LDG with ArtiSential® (LivsMed) graspers between April 2018 and August 2020 were enrolled in the study. The clinical outcomes were compared with those of a control group, in which prebent graspers (Olympus Medical Systems Corp) were used for the same procedures.

RESULTS

Seventeen patients were enrolled in the ArtiSential® group. There was no significant difference in operative time (205.4±6.0 vs. 218.1±9.9 minutes, P= 0.270) or the quality of surgery, in terms of the number of retrieved lymph nodes (49.5±3.5 vs. 45.9±4.0, P=0.473), length of hospital stay (15.4±2.0 vs. 12.4±1.3 days, P=0.588), and postoperative complications (40.0% vs. 41.2%, P=0.595), between the ArtiSential® group and the control group.

CONCLUSIONS

The new multi-DOF articulating grasper is feasible and can be used as an alternative for prebent graspers during SP-LDG.

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.

Short- and long-term comparison of robotic and laparoscopic gastrectomy for gastric cancer by the same surgical team: a propensity score matching analysis

BACKGROUND

Research on short-term outcomes and oncology results after robotic gastrectomy (RG) is still limited, especially from a single surgical team. The purpose of this study was to compare the short-term and long-term outcomes of robotic and laparoscopic gastrectomy (LG).

METHODS

Between October 2014 and September 2019, 1686 consecutive patients who underwent MIS gastrectomy were enrolled. The patients were divided into RG and LG groups according to surgical type. Groups were matched at a 1:1 ratio using propensity scores based on the following variables: age, sex, ASA score, primary tumor location, histologic type, pathological stage, and neoadjuvant chemotherapy. The primary outcomes were 3-year overall survival (OS) and relapse-free survival (RFS). The secondary outcomes were postoperative short-term outcomes.

RESULTS

Demographic and baseline characteristics were similar between the two groups after matching. Compared to the LG group, the RG group had a significantly higher retrieved lymph node (LN) number (32.15 vs 30.82, P = 0.040), more retrieved supra-pancreatic LNs (12.45 vs 11.61, P = 0.028), lower estimated blood loss (73.67 vs 98.08 ml, P < 0.001), but longer operation time (205.18 vs 185.27 min, P < 0.001) and higher hospitalization costs ($13,607 vs $10,928, P < 0.001) in the matched cohort. In the subgroup analysis, we observed that compared with LG, patients with advanced gastric cancer benefitted more from RG surgery. The matched cohort analysis demonstrated no statistically significant differences for 3-year OS or RFS (log-rank, P = 0.648 and P = 0.951, respectively): 80.3% and 77.0% in LG vs. 81.2% and 76.6% in RG, respectively.

CONCLUSION

RG has certain technical advantages over LG, especially in patients with advanced gastric cancer. However, RG does not improve long-term oncology outcomes.

Current status of robotic gastrectomy for gastric cancer: comparison with laparoscopic gastrectomy

Robotic systems were developed to overcome limitations of laparoscopic surgery with its mechanical advantages. Along with the technical advances, robotic gastrectomy for gastric cancer is increasing. However, the evidence regarding safety and efficacy for robotic gastrectomy for gastric cancer is not mature yet. Although studies are limited, it is evident that robotic gastrectomy has a longer operation and less blood loss compared with laparoscopic gastrectomy. Studies revealed long-term oncological outcomes after robotic gastrectomy was comparable to those after laparoscopic gastrectomy. Taken together, robotic gastrectomy with systemic lymph node dissection is suggested as a safe procedure with equivalent short- and long-term oncologic outcomes to either laparoscopic or open gastrectomy for the surgical treatment of gastric cancer. However, high cost is the most significant barrier to justify robotic surgery as a routine and standard treatment for patients with gastric cancer. In the meanwhile, robotic surgery will be expansively used as long as technologic developments continue.

Robot-assisted laparoscopic subtotal gastrectomy for early-stage gastric cancer: Case series of initial experience

BACKGROUND

In the last decade's robotic gastrectomy (RG) has increasingly widespread as a valid minimally invasive option for treatment of gastric cancer. In literature, evidence of its routine use is not yet well established. The aims of this study are to report our initial experience and to present possible advantages of our hybrid operative technique for subtotal gastrectomy.

MATERIALS AND METHODS

Retrospectively, we analyzed data from 41 patients (22 male and 19 female) who underwent robot-assisted laparoscopic subtotal gastrectomy (RALG) with D2 lymphadenectomy using the da Vinci XI robotic system. Inclusion criteria were gastric cancer in the middle or lower portion of the stomach amenable of radical subtotal gastrectomy without preoperative suspicion of positive lymph-nodes or other organs involving and distant metastasis. All the procedures were performed by attending surgeons.

RESULTS

The mean operative time was 270 min with one case of conversion to open surgery. The mean age was 71.4 (IQR 68.2-76.8) with 43.9% of patients classified as ASA (American Society of Anesthesiologists) score ≥3. The median of lymph-nodes retrieved was 25 (IQR 19-35). No intra-operative complications occurred. Time to resume a soft diet was 5 days. Patients were hospitalized a median of 7 days. According to pathological AJCC-TNM, 21 patients were classified as advanced gastric cancer. Post-operative morbidity was recorded in 9 patients (21.9%) with major complications requiring surgical operation in 4 patients (9.8%). Elevated ASA score, fewer lymph-nodes retrieved and ICU recovery requirements were significant increased in patients with major complications.

CONCLUSION

The preliminary results demonstrated that robot-assisted laparoscopic subtotal gastrectomy is safe and feasible. In particular, we found that the da Vinci platform improves surgeon abilities to perform an adequate lymphadenectomy and digestive reconstruction. Further studies are necessary to better clarify the role of this high-cost technology in minimally invasive treatment of gastric cancer.

Risk Factors for the Severity of Complications in Minimally Invasive Total Gastrectomy for Gastric Cancer: a Retrospective Cohort Study

Purpose

Minimally invasive gastrectomy is a promising surgical method with well-known benefits, including reduced postoperative complications. However, for total gastrectomy of gastric cancers, this approach does not significantly reduce the risk of complications. Therefore, we aimed to evaluate the incidence and risk factors for the severity of complications associated with minimally invasive total gastrectomy for gastric cancer.

Materials and Methods

The study included 392 consecutive patients with gastric cancer who underwent either laparoscopic or robotic total gastrectomy between 2011 and 2019. Clinicopathological and operative characteristics were assessed to determine the features related to postoperative complications after minimally invasive total gastrectomy. Binomial and multinomial logistic regression models were used to identify the risk factors for overall complications and mild and severe complications, respectively.

Results

Of 103 (26.3%) patients experiencing complications, 66 (16.8%) and 37 (9.4%) developed mild and severe complications, respectively. On multivariate multinomial regression analysis, independent predictors of severe complications included obesity (OR, 2.56; 95% CI, 1.02−6.43; P=0.046), advanced stage (OR, 2.90; 95% CI, 1.13−7.43; P=0.026), and more intraoperative bleeding (OR, 1.04; 95% CI, 1.02−1.06; P=0.001). Operation time was the only independent risk factor for mild complications (OR, 1.06; 95% CI, 1.001−1.13; P=0.047).

Conclusions

The risk factors for mild and severe complications were associated with surgery, indicating surgical difficulty. Surgeons should be aware of these potential risks that are related to the severity of complications so as to reduce surgery-related complications after minimally invasive total gastrectomy for gastric cancer.

Robotic versus laparoscopic gastrectomy for gastric cancer: a systematic review and meta-analysis

Background

To date, robotic surgery has been widely used worldwide. We conducted a systematic review and meta-analysis to evaluate short-term and long-term outcomes of robotic gastrectomy (RG) in gastric cancer patients to determine whether RG can replace laparoscopic gastrectomy (LG).

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was applied to perform the study. Pubmed, Cochrane Library, WanFang, China National Knowledge Infrastructure (CNKI), and VIP databases were comprehensively searched for studies published before May 2020 that compared RG with LG. Next, two independent reviewers conducted literature screening and data extraction. The quality of the literature was assessed using the Newcastle-Ottawa Scale (NOS), and the data analyzed using the Review Manager 5.3 software. Random effects or fixed effects models were applied according to heterogeneity.

Results

A total of 19 studies including 7275 patients were included in the meta-analyses, of which 4598 patients were in the LG group and 2677 in the RG group. Compared with LG, RG was associated with longer operative time (WMD = −32.96, 95% CI −42.08 ~ −23.84, P < 0.001), less blood loss (WMD = 28.66, 95% CI 18.59 ~ 38.73, P < 0.001), and shorter time to first flatus (WMD = 0.16 95% CI 0.06 ~ 0.27, P = 0.003). There was no significant difference between RG and LG in terms of the hospital stay (WMD = 0.23, 95% CI −0.53 ~ 0.98, P = 0.560), overall postoperative complication (OR = 1.07, 95% CI 0.91 ~ 1.25, P = 0.430), mortality (OR = 0.67, 95% CI 0.24 ~ 1.90, P = 0.450), the number of harvested lymph nodes (WMD = −0.96, 95% CI −2.12 ~ 0.20, P = 0.100), proximal resection margin (WMD = −0.10, 95% CI −0.29 ~ 0.09, P = 0.300), and distal resection margin (WMD = 0.15, 95% CI −0.21 ~ 0.52, P = 0.410). No significant differences were found between the two treatments in overall survival (OS) (HR = 0.95, 95% CI 0.76 ~ 1.18, P = 0.640), recurrence-free survival (RFS) (HR = 0.91, 95% CI 0.69 ~ 1.21, P = 0.530), and recurrence rate (OR = 0.90, 95% CI 0.67 ~ 1.21, P = 0.500).

Conclusions

The results of this study suggested that RG is as acceptable as LG in terms of short-term and long-term outcomes. RG can be performed as effectively and safely as LG. Moreover, more randomized controlled trials comparing the two techniques with rigorous study designs are still essential to evaluate the value of the robotic surgery for gastric cancer.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12957-020-02080-7.

Application of da Vinci robot with the"3 + 2" mode in radical gastrectomy for gastric cancer

The aim of this study is to investigate the feasibility and advantages of the da Vinci robotic system with the "3 + 2" mode (3 robotic arms and 2 assistants) in radical gastrectomy for gastric cancer.The clinical data of 65 patients who underwent da Vinci robotic gastrectomy with the "3 + 2" mode from July 2016 to October 2019 were grouped into an observation group. An additional 65 patients who underwent robotic gastrectomy under the classic mode during the same period were grouped into a control group. The short-term surgical outcomes were compared between 2 different groups.Compared with the control group, the observation group had a significantly shorter operative time (176.18 ± 15.49 vs 203.85 ± 12.77 minutes, P < .001) and lower operation costs ($2761.19 ± $191.91 vs $3690.91 ± $162.82; P < .001). No statistical differences in other outcomes were observed (P > .05).We show that robotic gastrectomy with "3 + 2" mode is a safe and beneficial surgical procedure in new robotic surgery institutions.

Robotic versus laparoscopic gastrectomy for gastric cancer: The largest meta-analysis

BACKGROUND

Minimally invasive surgery (MIS) has been increasingly used in the treatment of gastric cancer (GC). Laparoscopic gastrectomy (LG) has shown several advantages over open surgery in dealing with GC, although it is still considered a demanding procedure. Robotic gastrectomy (RG) is now being employed with increased frequency worldwide and has been reported to overcome some limitations of conventional LG. The aim of this updated meta-analysis is to compare surgical and oncological outcomes of RG versus LG for gastric cancer.

MATERIALS AND METHODS

A systematic review and meta-analysis was conducted using the PubMed, MEDLINE and Cochrane library database of published studies comparing RG and LG up to March 2020. The evaluated end-points were intra-operative, post-operative and oncological outcomes. Dichotomous data were calculated by odds ratio (OR) and continuous data were calculated by mean difference (MD) with 95% confidence intervals (95% CI), and a random-effect model was always applied.

RESULTS

Forty retrospective studies describing 17,712 patients met the inclusion criteria. With respect to surgical outcomes, robotic compared with laparoscopic gastrectomy was associated with higher operating time [MD 44.73, (95%CI 36.01, 53.45) p < 0.00001] and less intraoperative blood loss [MD -18.24, (95%CI -25.21, -11.26) p < 0.00001] and lower rate of surgical complication in terms of Dindo-Clavien ≥ 3 classification [OR 0.66, (95%CI 0.49, 0.88) p = 0.005]. With respect to oncological outcomes, the RG group showed a significantly increased mean number of retrieved lymph nodes [MD 1.84, (95%CI 0.84, 2.84) p = 0.0003], but mean proximal and distal resection margin distance and the recurrence rate were not significantly different between the two approaches.

CONCLUSIONS

With respect to safety, technical feasibility and oncological adequacy, robotic and laparoscopic groups were comparable, although the robotic approach seems to achieve better short-term surgical outcomes. Moreover, a higher rate of retrieved lymph nodes was observed in the RG group.

Robotic Gastrectomy for Gastric Adenocarcinoma in the USA: Insights and Oncologic Outcomes in 220 Patients

BACKGROUND

While multiple Asian and a few Western retrospective series have demonstrated the feasibility and safety of robotic-assisted gastrectomy for gastric cancer, its reliability for thorough resection, especially for locoregional disease, has not yet been firmly established, and reported learning curves vary widely. To support wider implementation of robotic gastrectomy, we evaluated the learning curve for this approach, assessed its oncologic feasibility, and created a selection model predicting the likelihood of conversion to open surgery in a US patient population.

PATIENTS AND METHODS

We retrospectively reviewed data on all consecutive patients who underwent robotic gastrectomy at a high-volume institution between May 2012 and March 2019.

RESULTS

Of the 220 patients with gastric cancer selected to undergo curative-intent robotic gastrectomy, surgery was completed using robotics in 159 (72.3%). The median number of removed lymph nodes was 28, and ≥ 15 lymph nodes were removed in 94% of procedures. Surgical time decreased steadily over the first 60-80 cases. Complications were generally minor: 7% of patients experienced complications of grade 3 or higher, with an anastomotic leak rate of 2% and mortality rate 0.9%. Factors predicting conversion to open surgery included neoadjuvant chemotherapy, BMI ≥ 31 kg/m², and tumor size ≥ 6 cm.

CONCLUSIONS

These findings support the safety and oncologic feasibility of robotic gastrectomy for selected patients with gastric cancer. Proficiency can be achieved by 20 cases and mastery by 60-80 cases. Ideal candidates for this approach are patients with few comorbidities, BMI < 31 kg/m², and tumors < 6 cm.

Effectiveness and safety of robotic versus traditional laparoscopic gastrectomy for gastric cancer: An updated systematic review and meta-analysis

Gastrectomy is considered the gold standard treatment for gastric cancer patients. Currently, there are two minimally invasive surgical methods to choose from, robotic gastrectomy (RG) and laparoscopic gastrectomy (LG). Nevertheless, it is still unclear which is superior between the two. This meta-analysis aimed to investigate the effectiveness and safety of RG and LG for gastric cancer. A systematic literature search was performed using PubMed, Embase, and the Cochrane Library databases until September 2018 in studies that compared RG and LG in gastric cancer patients. Operative and postoperative outcomes analyzed were assessed. The quality of the evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluations. Twenty-four English studies were analyzed. The meta-analysis revealed that the RG group had a significantly longer operation time, lower intraoperative blood loss, and higher perioperative costs compared to the LG group. However, there were no differences in complications, conversion rate, reoperation rate, mortality, number of lymph nodes harvested, days of first flatus, postoperative hospitalization time, and survival rate between the two groups. RG was shown to be associated with decreased intraoperative blood loss and increased perioperative cost and operation time compared to LG. Several higher-quality original studies and prospective clinical trials are required to confirm the advantages of RG.

Outcomes of Gastric Resection in the Establishment of a Comprehensive Oncologic Robotic Program

BACKGROUND

Robotic-assisted gastrectomy is increasingly utilized for the treatment of gastric malignancies. However, the benefits of robotic surgery have been questioned. This study describes short-term outcomes in the establishment of a comprehensive robotic program for gastric malignancies.

MATERIALS AND METHODS

Patients who underwent robotic-assisted gastric resections between 2013 and 2018 were studied. Preoperative measures and surgical outcomes were analyzed. Finally we studied and analyzed robotic and open gastrectomy for the management of gastric adenocarcinoma (GC) at the same institution between 2000 and 2018 for quality benchmarking.

RESULTS

Forty six patients (pts.) underwent robotic-assisted gastric resections. 26 (56.5%) were male, with a median age of 62 y (range: 29-87). Pathology included GC, gastrointestinal stromal tumors, neuroendocrine tumors, metastatic lesions, and benign processes. 19 pts. underwent total gastrectomy, 16 distal gastrectomy, four subtotal gastrectomy, and seven wedge resection. Pts. undergoing distal gastrectomy and wedge resection experienced shorter operative times and length of stay than total gastrectomy (P < 0.01; P < 0.01). Four operations (8.8%) were converted to open and 13 pts (28.3%) had postoperative complications, including an 8.7% readmission rate. Median lymph nodes retrieved during total, subtotal, and distal gastrectomy were 20 (13-46), 12.5 (0-26), and 16.5 (0-34), respectively. All pts. underwent margin negative resection. Median follow-up for GC was 21 mo, and 60% of pts. received adjuvant therapy at a median of 59d (range: 23-106).

CONCLUSIONS

Robotic gastrectomy is a feasible alternative to open gastrectomy. Our results will help establish benchmarks to improve perioperative outcomes, especially length of stay and time to initiation of therapy.

Minimally invasive gastrectomy for cancer and anastomotic options

In this review article, we explore patient selection criteria for minimally invasive surgery (MIS) gastrectomy, present evidence on the risks and benefits of minimally invasive techniques, describe operative techniques focusing specifically on reconstruction options, and discuss the learning curve associated with these operations.

Short-Term Clinical Outcomes After Laparoscopic and Robotic Gastrectomy for Gastric Cancer: a Propensity Score Matching Analysis

BACKGROUND

The different advantages of laparoscopic gastrectomy (LG) and robotic gastrectomy (RG), two new minimally invasive surgical techniques for gastric cancer, remain controversial.

PURPOSE

To compare the short-term clinical outcomes of LG and RG.

METHODS

A retrospective, single-center comparative study of 1044 patients (LG = 750, RG = 294) was conducted. Patients undergoing LG and RG were matched (2:1 ratio) according to sex, age, BMI, extent of gastric resection, and pathologic stage. The primary outcomes were morbidity and mortality and perioperative recovery parameters; major types of complications were also analyzed.

RESULTS

After matching, 798 patients (LG = 532, RG = 266) were included. Both the LG and RG groups showed similar overall complication rates (LG = 12.8% vs RG = 12.4%) and operative mortality (LG = 0.4% vs RG = 0.4%). Compared to those who underwent LG, patients undergoing RG had significantly longer operative times (236.92 ± 57.28 vs 217.77 ± 65.00 min, p < 0.001), higher total costs (US$16,241.42 vs US$12,497, p < 0.001), less operative blood loss (77.07 ± 64.37 vs 103.68 ± 86.92 ml, p < 0.001), higher numbers of retrieved lymph nodes (32.0 vs 29.9, p < 0.001), and higher rates of retrieving more than 16 lymph nodes (94.0 vs 85.5%; p < 0.001). No significant differences between groups were noted in terms of the rate of reoperation, time until a soft diet was consumed, or length of hospital stay. The major complication and readmission rates were similar in both groups.

CONCLUSION

RG and LG produced similar short-term clinical outcomes, indicating that RG is a safe and beneficial surgical procedure.

Robotic versus laparoscopic gastrectomy for gastric cancer: protocol for umbrella review of systematic reviews and meta-analyses

INTRODUCTION

Laparoscopic surgery has been adopted in some parts of the world as an innovative approach to the resection of gastric cancers. However, in the modern era of surgical oncology, to overcome intrinsic limitations of the traditional laparoscopy, the robotic approach is advocated as able to facilitate the lymph node dissection and complex reconstruction after gastrectomy, to assure oncologic safety also in advanced gastric cancer patients. Previous meta-analyses highlighted a lower complication rate as well as bleeding in the robotic approach group when compared with the laparoscopic one. This potential benefit must be balanced against an increased time of intervention. The aim of this umbrella review is to provide a comprehensive overview of the literature for surgeons and policymakers in order to evaluate the potential benefits and harms of robotic gastrectomy (RG) compared with the laparoscopic approach for gastric cancer.

METHODS AND ANALYSIS

We will perform a comprehensive search of the PubMed, Cochrane and Embase databases for all articles published up to May 2019 and reference list of relevant publications for systematic review and meta-analyses comparing the outcomes of RG and laparoscopic gastrectomy in patients with gastric cancer. Studies will be selected by two independent reviewers based on prespecified eligibility criteria and the quality will be assessed according to AMSTAR (A MeaSurement Tool to Assess systematic Reviews) checklist. All information will be collected using piloted and standardised data-extraction forms in DistillerSR developed following the Joanna Briggs Institute's recommended extraction items.

ETHICS AND DISSEMINATION

This umbrella review will inform clinical and policy decisions regarding the benefits and harms of RG for treating gastric cancer. The results will be disseminated through a peer-reviewed publication, conference presentations and the popular press. Formal ethical approval is not required as primary data will not be collected.

PROSPERO REGISTRATION NUMBER

CRD42019139906.

Oncological Robot-Assisted Gastrectomy: Technical Aspects and Ongoing Data

Robotic surgery through the da Vinci Surgical System has been widely spread for many procedures across the globe for several years. At the same time, robot-assisted gastrectomy for gastric cancer (GC) remains mostly available only in specialized centers in minimally invasive surgery and stomach neoplasm. The robotic platform has been introduced to overcome possible drawbacks of the laparoscopic approach. The safety and the feasibility of robotic radical gastrectomy have been reported in many retrospective case series and nonrandomized prospective studies. However, the superiority of robotic gastrectomy over the laparoscopic access has not yet been proven. This study aimed to report the technical aspects of robot-assisted gastrectomy for GC as well as the latest evidence on this subject.

Enhanced recovery after surgery for gastric cancer (ERAS-GC): optimizing patient outcome

Significant advances were achieved, in last decades, in the management of surgical patients with gastric cancer. This has led to the concept of enhanced recovery after surgery (ERAS) with the objective of reducing the length of hospital stay, accelerating postoperative recovery and reducing the surgical stress. The ERAS protocols have many items, including the pre-operative patient education, early mobilization and feeding starting from the first postoperative day. This review aims to highlight possible advantages on postoperative functional recovery outcomes after gastrectomy in patients undergoing an ERAS program, current lack of evidences and future perspectives.

Robot-Assisted versus Laparoscopic-Assisted Gastrectomy among Gastric Cancer Patients: A Retrospective Short-Term Analysis from a Single Institution in China

Background

The da Vinci robotic system was considered an effectively alternative treatment option for early gastric cancer patients in recent years. The aim of our study was to evaluate the safety and feasibility of robot-assisted gastrectomy in our center.

Methods

This study included 33 patients who underwent robot-assisted gastrectomy (RAG) and 88 patients who underwent laparoscopic-assisted gastrectomy (LAG) between January 2016 and April 2018. Clinicopathological characteristics, surgical parameters, postoperative recovery, and the learning curves of RAG were evaluated.

Results

Baseline characteristics between two groups were well balanced. The operation time of RAG was longer than that of LAG (333.1 ± 61.4 min vs. 290.6 ± 39.0 min, p = 0.001), and the estimated blood loss was 62.4 ± 41.2 ml in the RAG group and 77.7 ± 32.3 ml in the LAG group (p = 0.005), respectively. The mean number of examined lymph nodes in RAG was less than that in LAG (30.3 ± 10.2 vs. 37.4 ± 13.7, p = 0.008). However, RAG had an advantage in the dissection of No. 9 lymph nodes (3.4 ± 2.1 vs. 2.5 ± 1.6, p = 0.039). The incidence of postoperative complications was similar in both groups (p = 0.735). There were no significant differences in terms of postoperative recovery between the two groups. The learning curve of RAG showed that the CUSUM value decreased from the 8th case, which suggested a rapid learning curve among experienced surgeons on LAG operations.

Conclusions

RAG was safe and feasible for gastric cancer patients, with superiority in the dissection of No. 9 lymph nodes.

Precision medicine in gastric cancer

Gastric cancer (GC) is a complex disease linked to a series of environmental factors and unhealthy lifestyle habits, and especially to genetic alterations. GC represents the second leading cause of cancer-related deaths worldwide. Its onset is subtle, and the majority of patients are diagnosed once the cancer is already advanced. In recent years, there have been innovations in the management of advanced GC including the introduction of new classifications based on its molecular characteristics. Thanks to new technologies such as next-generation sequencing and microarray, the Cancer Genome Atlas and Asian Cancer Research Group classifications have also paved the way for precision medicine in GC, making it possible to integrate diagnostic and therapeutic methods. Among the objectives of the subdivision of GC into subtypes is to select patients in whom molecular targeted drugs can achieve the best results; many lines of research have been initiated to this end. After phase III clinical trials, trastuzumab, anti-Erb-B2 receptor tyrosine kinase 2 (commonly known as ERBB2) and ramucirumab, anti-vascular endothelial growth factor receptor 2 (commonly known as VEGFR2) monoclonal antibodies, were approved and introduced into first- and second-line therapies for patients with advanced/metastatic GC. However, the heterogeneity of this neoplasia makes the practical application of such approaches difficult. Unfortunately, scientific progress has not been matched by progress in clinical practice in terms of significant improvements in prognosis. Survival continues to be low in contrast to the reduction in deaths from many common cancers such as colorectal, lung, breast, and prostate cancers. Although several target molecules have been identified on which targeted drugs can act and novel products have been introduced into experimental therapeutic protocols, the overall approach to treating advanced stage GC has not substantially changed. Currently, surgical resection with adjuvant or neoadjuvant radiotherapy and chemotherapy are the most effective treatments for this disease. Future research should not underestimate the heterogeneity of GC when developing diagnostic and therapeutic strategies aimed toward improving patient survival.

Short-term efficacy of robotic and laparoscopic spleen-preserving splenic hilar lymphadenectomy via Huang's three-step maneuver for advanced upper gastric cancer: Results from a propensity score-matched study

BACKGROUND

Robotic surgery has been considered to be significantly better than laparoscopic surgery for complicated procedures.

AIM

To explore the short-term effect of robotic and laparoscopic spleen-preserving splenic hilar lymphadenectomy (SPSHL) for advanced gastric cancer (GC) by Huang’s three-step maneuver.

METHODS

A total of 643 patients who underwent SPSHL were recruited from April 2012 to July 2017, including 35 patients who underwent robotic SPSHL (RSPSHL) and 608 who underwent laparoscopic SPSHL (LSPSHL). One-to-four propensity score matching was used to analyze the differences in clinical data between patients who underwent robotic SPSHL and those who underwent laparoscopic SPSHL.

RESULTS

In all, 175 patients were matched, including 35 patients who underwent RSPSHL and 140 who underwent LSPSHL. After matching, there were no significant differences detected in the baseline characteristics between the two groups. Significant differences in total operative time, estimated blood loss (EBL), splenic hilar blood loss (SHBL), splenic hilar dissection time (SHDT), and splenic trunk dissection time were evident between these groups (P < 0.05). Furthermore, no significant differences were observed between the two groups in the overall noncompliance rate of lymph node (LN) dissection (62.9% vs 60%, P = 0.757), number of retrieved No. 10 LNs (3.1 ± 1.4 vs 3.3 ± 2.5, P = 0.650), total number of examined LNs (37.8 ± 13.1 vs 40.6 ± 13.6, P = 0.274), and postoperative complications (14.3% vs 17.9%, P = 0.616). A stratified analysis that divided the patients receiving RSPSHL into an early group (EG) and a late group (LG) revealed that the LG experienced obvious improvements in SHDT and length of stay compared with the EG (P < 0.05). Logistic regression showed that robotic surgery was a significantly protective factor against both SHBL and SHDT (P < 0.05).

CONCLUSION

RSPSHL is safe and feasible, especially after overcoming the early learning curve, as this procedure results in a radical curative effect equivalent to that of LSPSHL.

Robotic-assisted versus conventional laparoscopic-assisted total gastrectomy with D2 lymphadenectomy for advanced gastric cancer: short-term outcomes at a mono-institution

BACKGROUND

Robotic-assisted surgery, a developed technology, is becoming more and more accepted by surgeons. However, the comparison between robotic-assisted total gastrectomy (RATG) and conventional laparoscopy-assisted total gastrectomy (LATG) for advanced gastric cancer (AGC) is seldom reported, or usually the sample sizes reported are small. The current research was designed to compare the short-term outcomes of RATG and LATG with D2 lymphadenectomy for AGC in a mono-institution from China.

METHODS

A total of 205 patients from June 2015 to October 2018 were included in this study. Among them, 106 patients underwent LATG, and 99 patients underwent RATG. The patients' clinicopathological characteristics, surgical performance and short-term outcomes were retrospectively analyzed.

RESULTS

The clinicopathological characteristics showed no difference between the LATG group and the RATG group. However, compared with the LATG group, the operation time was longer (P = 0.000), and the operative blood loss (P = 0.000) and the volume of abdominal drainage was less (P = 0.000) in the RATG group. Moreover, the RATG took less time to remove abdominal drainage tube than LATG (P = 0.000). The plasma levels of CRP at 72 h post-operation was lower (P = 0.000), and the number of retrieved lymph nodes was more (P = 0.000) in the RATG group. Nevertheless, the postoperative length of stay (P = 0.890), the time to first flatus (P = 0.448), the postoperative complication (P = 0.915) and the visual analogue pain score at 24 h post-operation (P = 0.457) were comparable between the two groups.

CONCLUSIONS

RATG with D2 lymphadenectomy shows safety and feasibility for AGC and could be served as an alternative treatment for AGC in the future.

An Efficient Single-session Spatial Skill Trainer for Robot-assisted Surgery: A Randomized Trial

STUDY OBJECTIVE

To introduce and examine a single session of spatial skill training as an efficient means of improving surgical suturing performance in robot-assisted surgery.

DESIGN

A randomized, controlled trial.

SETTING

A tertiary university medical center in Israel.

PARTICIPANTS

A purposive sample composed of 41 residents with no robotic suturing skills.

INTERVENTIONS

A computer-based simulator training of spatial skills.

MEASUREMENTS AND MAIN RESULTS

Participants were randomly assigned to training (n = 21: mean age of 34 years [standard deviation (SD) = 1.92]) and control (n = 20: mean age of 32 years [SD = 3.17]) conditions. The training group underwent a session of spatial skills training, whereas the control group engaged in a neutral activity. After 1 participant was lost to the follow-up of the posttraining performance test, data of 40 participants were analyzed. Robotic suturing task performance with the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA) was evaluated using the da Vinci Skills Simulator built-in measure of "excess tissue piercing" and an expert rating of "tissue tearing." The mean number of excess tissue piercing after training (but not after the neutral activity) was significantly lower than before training (3.25 [SD = 1.996] vs 6.75 [SD = 3.68], respectively; p <.001), reflecting an improvement of 52% (decreasing the mean number of excess tissue piercing in a single suture by 3.5 excess piercing trials). After the interventions, the extent of tissue tearing was rated lower in the training group (p = .01), and there was no change in the control group (p = .14).

CONCLUSION

We showed the efficiency of a training approach that focuses on spatial skills critical in robot-assisted surgery. We showed that surgeons who received a 1 session spatial skill training with a cognitive spatial skill trainer immediately improved the performance of a robotic suturing task compared with surgeons who did not receive such training.

[Minimally invasive and robotic-assisted surgical management of upper gastrointestinal cancer]

Total minimally invasive upper gastrointestinal resections are currently mainly performed in centers. The advantages include reduction of operative trauma, magnified enlargement of the operation field and the resulting improvement in operative precision. Robotic-assisted minimally invasive esophagectomy (RAMIE) and laparoscopic/thoracoscopic minimally invasive esophagectomy (MIE) are currently the most commonly performed strategies for esophageal cancer. Laparoscopic (MIG) and robotic-assisted gastrectomy (RAG) are the equivalent procedures for gastric cancer. Due to the relatively low number of reported cases, no definitive statement regarding superiority of these procedures compared to standard open or hybrid procedures can be made; however, there is mounting evidence from high-volume centers in which these procedures are routinely performed that there might be an advantage regarding perioperative morbidity. All of the four procedures described are provided at our high-volume centers in a standardized manner and we are convinced of the benefits of these minimally invasive techniques with respect to morbidity compared to open and hybrid techniques. The additional costs of this technology have to be off-set against a possible reduction of morbidity, reduced cost for personnel and new operative options, such as real-time fluoroscopy.