Comparison of surgical performance and short-term clinical outcomes between laparoscopic and robotic surgery in distal gastric cancer

Robot-assisted laparoscopic gastrectomy for gastric cancer

Phase III evidence in the shape of a series of randomized controlled trials and meta-analyses has shown that laparoscopic gastrectomy is safe and gives better short-term results with respect to the traditional open technique for early-stage gastric cancer. In fact, in the East laparoscopic gastrectomy has become routine for early-stage gastric cancer. In contrast, the treatment of advanced gastric cancer through a minimally invasive way is still a debated issue, mostly due to worries about its oncological efficacy and the difficulty of carrying out an extended lymphadenectomy and intestinal reconstruction after total gastrectomy laparoscopically. Over the last ten years the introduction of robotic surgery has implied overcoming some intrinsic drawbacks found to be present in the conventional laparoscopic procedure. Robot-assisted gastrectomy with D2 lymphadenectomy has been shown to be safe and feasible for the treatment of gastric cancer patients. But unfortunately, most available studies investigating the robotic gastrectomy for gastric cancer compared to laparoscopic and open technique are so far retrospective and there have not been phase III trials. In the present review we looked at scientific evidence available today regarding the new high-tech surgical robotic approach, and we attempted to bring to light the real advantages of robot-assisted gastrectomy compared to the traditional laparoscopic and open technique for the treatment of gastric cancer.

Comparison of short outcomes between laparoscopic and experienced robotic gastrectomy: A meta-analysis and systematic review

OBJECTIVE:

The purpose of this meta-analysis is to compare the short-term outcomes between experienced robotic gastrectomy (RG) and laparoscopic gastrectomy (LG).

MATERIALS AND METHODS:

We searched the PubMed, Springer Link, Elsevier, and Embase databases for articles published in English before June 2015 using an electronic literature search and including cross-referenced articles. Three studies were eligible for the meta-analysis. The outcomes evaluated were operation time, estimated blood loss, harvested lymph nodes, complication, and postoperative hospital stay.

RESULTS:

Of a total of 562 patients, 165 underwent RG and 397 underwent LG. Operation time was significantly longer in the RG group [weighted mean difference (WMD): 21.49, 95% confidence interval (CI): 12.48-30.50, P < 0.00001). Estimated blood loss, harvested lymph nodes, complication, and postoperative hospital stay were similar between the two groups.

CONCLUSION:

Experienced RG has similar short-term outcomes to LG that is performed by sophisticated laparoscopic surgeons, except for operation time.

Robotic surgery for upper gastrointestinal cancer: Current status and future perspectives

Robotic surgery with the da Vinci Surgical System has been increasingly applied in a wide range of surgical specialties, especially in urology and gynecology. However, in the field of upper gastrointestinal (GI) tract, the da Vinci Surgical System has yet to be standard as a result of a lack of clear benefits in comparison with conventional minimally invasive surgery. We have been carrying out robotic gastrectomy and esophagectomy for operable patients with resectable upper GI malignancies since 2009, and have demonstrated the potential advantages of the use of the robot in possibly reducing postoperative local complications including pancreatic fistula following gastrectomy and recurrent laryngeal nerve palsy after esophagectomy, even though there have been a couple of problems to be solved including longer duration of operation and higher cost. The present review provides updates on robotic surgery for gastric and esophageal cancer based on our experience and review of the literature.

Robotic vs laparoscopic distal gastrectomy with D2 lymphadenectomy for gastric cancer: a retrospective comparative mono-institutional study

Background

Robotic surgery has been developed with the aim of improving surgical quality and overcoming the limitations of conventional laparoscopy in the performance of complex mini-invasive procedures. The present study was designed to compare robotic and laparoscopic distal gastrectomy in the treatment of gastric cancer.

Methods

Between June 2008 and September 2015, 41 laparoscopic and 30 robotic distal gastrectomies were performed by a single surgeon at the same institution. Clinicopathological characteristics of the patients, surgical performance, postoperative morbidity/mortality and pathologic data were prospectively collected and compared between the laparoscopic and robotic groups by the Chi-square test and the Mann-Whitney test, as indicated.

Results

There were no significant differences in patient characteristics between the two groups. Mean tumor size was larger in the laparoscopic than in the robotic patients (5.3 ± 0.5 cm and 3.0 ± 0.4 cm, respectively; P = 0.02). However, tumor stage distribution was similar between the two groups. The mean number of dissected lymph nodes was higher in the robotic than in the laparoscopic patients (39.1 ± 3.7 and 30.5 ± 2.0, respectively; P = 0.02). The mean operative time was 262.6 ± 8.6 min in the laparoscopic group and 312.6 ± 15.7 min in the robotic group (P < 0.001). The incidences of surgery-related and surgery-unrelated complications were similar in the laparoscopic and in the robotic patients. There were no significant differences in short-term clinical outcomes between the two groups.

Conclusions

Within the limitation of a small-sized, non-randomized analysis, our study confirms that robotic distal gastrectomy is a feasible and safe surgical procedure. When compared with conventional laparoscopy, robotic surgery shows evident benefits in the performance of lymphadenectomy with a higher number of retrieved and examined lymph nodes.

Laparoscopic and robot-assisted gastrectomy for gastric cancer: Current considerations

Radical gastrectomy with an adequate lymphadenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer (GC). A number of randomized controlled trials and meta-analysis provide phase III evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage GC. While laparoscopic gastrectomy has become standard therapy for early-stage GC, especially in Asian countries such as Japan and South Korea, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Some intrinsic drawbacks of the conventional laparoscopic technique have prevented the worldwide spread of laparoscopic gastrectomy for cancer and, despite technological advances in recent year, it remains a technically challenging procedure. The introduction of robotic surgery over the last ten years has implied a notable mutation of certain minimally invasive procedures, making it possible to overcome some limitations of the traditional laparoscopic technique. Robot-assisted gastric resection with D2 lymph node dissection has been shown to be safe and feasible in prospective and retrospective studies. However, to date there are no high quality comparative studies investigating the advantages of a robotic approach to GC over traditional laparoscopic and open gastrectomy. On the basis of the literature review here presented, robot-assisted surgery seems to fulfill oncologic criteria for D2 dissection and has a comparable oncologic outcome to traditional laparoscopic and open procedure. Robot-assisted gastrectomy was associated with the trend toward a shorter hospital stay with a comparable morbidity of conventional laparoscopic and open gastrectomy, but randomized clinical trials and longer follow-ups are needed to evaluate the possible influence of robot gastrectomy on GC patient survival.

Robotic surgery for gastric tumor: current status and new approaches

Surgical techniques have evolved tremendously over this past century. To maximize the efficacy and minimize the invasiveness of laparoscopic surgery, researchers have sought to implement wider application of robotics. Nevertheless, both optimism without sound evidence and fear of new technology obscure the appropriate uses of robotic surgery. In the present review, we attempted to provide a balanced perspective on the current state of robotic gastrectomy, outlining evidence and opportunities for the use thereof. Although evidence is limited, the use of robotics is feasible for gastric cancer surgery, and less than 10 cases of robotic surgery are needed to become proficient therein. Compared to the clinical impact of laparoscopy on gastric cancer surgery, the additional benefits of robotic surgery to patients seem to be limited. Despite additional costs and longer surgeries, robotic surgery reportedly does not offer surgical outcomes superior to those for laparoscopic surgery, according to a recent multicenter study. Meanwhile, however, our in-depth review of retrospective and prospective reports revealed that robots could expand the indications of minimally invasive gastrectomy for patients requiring total gastrectomy and D2 lymph node dissection. Moreover, we found that robotic gastrectomy is associated with a higher number of retrieved lymph nodes, less bleeding, fewer complications, and shorter hospital stay, compared to laparoscopic gastrectomy. Accordingly, new surgical approaches using advanced technologies, such as near infrared detectors, the Tilepro^® multi-input display, dual consoles, and the Single-Site^® system, are under investigation. In conclusion, measuring the additional benefits of robotic over laparoscopic surgery would be difficult and clinically insignificant. Thus, developing new surgical procedures that extend the benefits of conventional laparoscopic surgery to patients in whom minimally invasive surgery would not be possible is necessary to justify the greater use of robotic surgery.

Robot-assisted gastrectomy for early gastric cancer: is it beneficial in viscerally obese patients compared to laparoscopic gastrectomy?

BACKGROUND

The adoption of robotic systems for gastric cancer surgery has been proven feasible and safe; however, a benefit over the laparoscopic approach has not yet been well-documented. We aimed to investigate the surgical outcomes of robotic versus laparoscopic gastrectomy for gastric cancer, according to the extent of surgery and patients' obesity status.

METHODS

Between January 2009 and July 2011, 770 patients were enrolled in this retrospective analysis. All had stage IA/IB gastric cancer preoperatively and underwent either laparoscopic (n = 622) or robotic (n = 148) gastrectomy. Patients were classified into obese and non-obese groups on the basis of visceral fat area (VFA). The extent of surgery was defined by whether patients underwent distal or total gastrectomy.

RESULTS

The surgical outcomes following distal gastrectomy were similar between the robotic and laparoscopic groups regardless of the obesity status. After total gastrectomy, the number of total and N2-area lymph nodes were significantly higher in the robotic group than in the laparoscopic group in non-obese patients with VFA < 100 cm(2) (total, 38.8 vs. 46.5; p = 0.018; N2 area, 9.0 vs. 12.4; p = 0.041), but no significant differences were observed in obese population. Robotic group developed less severe complications after total gastrectomy compared to laparoscopic group in non-obese patients (p = 0.036).

CONCLUSION

Robotic assistance did not improve surgical outcomes over the laparoscopic approach in obese patients undergoing distal gastrectomy. However, non-obese patients with low VFA may benefit from robotic assistance during total gastrectomy in terms of radical D2 lymphadenectomy with fewer serious complications.

Robot-assisted surgery for gastric cancer

Minimally invasive surgery for gastric cancer is a relatively new research field, with convincing results mostly stemming from Asian countries. The use of the robotic surgery platform, thus far assessed as a safe procedure, which is also easier to learn, sets the background for a wider spread of minimally invasive technique in the treatment of gastric cancer. This review will cover the literature published so far, analyzing the pros and cons of robotic surgery and highlighting the remaining study questions.

Robotic Total Gastrectomy With Intracorporeal Robot-Sewn Anastomosis: A Novel Approach Adopting the Double-Loop Reconstruction Method

Gastric cancer constitutes a major health problem. Robotic surgery has been progressively developed in this field. Although the feasibility of robotic procedures has been demonstrated, there are unresolved aspects being debated, including the reproducibility of intracorporeal in place of extracorporeal anastomosis.Difficulties of traditional laparoscopy have been described and there are well-known advantages of robotic systems, but few articles in literature describe a full robotic execution of the reconstructive phase while others do not give a thorough explanation how this phase was run.A new reconstructive approach, not yet described in literature, was recently adopted at our Center.Robotic total gastrectomy with D2 lymphadenectomy and a so-called "double-loop" reconstruction method with intracorporeal robot-sewn anastomosis (Parisi's technique) was performed in all reported cases.Preoperative, intraoperative, and postoperative data were collected and a technical note was documented.All tumors were located at the upper third of the stomach, and no conversions or intraoperative complications occurred. Histopathological analysis showed R0 resection obtained in all specimens. Hospital stay was regular in all patients and discharge was recommended starting from the 4th postoperative day. No major postoperative complications or reoperations occurred.Reconstruction of the digestive tract after total gastrectomy is one of the main areas of surgical research in the treatment of gastric cancer and in the field of minimally invasive surgery.The double-loop method is a valid simplification of the traditional technique of construction of the Roux-limb that could increase the feasibility and safety in performing a full hand-sewn intracorporeal reconstruction and it appears to fit the characteristics of the robotic system thus obtaining excellent postoperative clinical outcomes.

Role of robot-assisted distal gastrectomy compared to laparoscopy-assisted distal gastrectomy in suprapancreatic nodal dissection for gastric cancer

PURPOSE

Despite theoretical advantages, no clear benefit was proven for initial application of robotic surgery for gastric cancer so far. The aim of this analysis was to examine the role of robotic surgery regarding nodal dissection technically demanding areas compared to conventional laparoscopic surgery.

METHODS

This analysis included 87 patients who underwent robot-assisted distal gastrectomy (RADG) and 288 patients who underwent laparoscopy-assisted distal gastrectomy (LADG) at the National Cancer Center, Korea, between February 2009 and September 2011. Clinicopathologic data, surgery-related data, postoperative morbidity, and pathologic data for each nodal station were analyzed.

RESULTS

Time to flatulence was 3.5 ± 0.8 days for RADG and 3.8 ± 0.8 days for LADG (P = 0.01). Postoperative hospital stay was 6.7 ± 1.0 days in RADG and 7.4 ± 2.4 days in LADG (P < 0.001).The number of dissected lymph nodes was 37.1 ± 12.9 in the RADG group and 34.1 ± 12.1 in the LADG group (P = 0.044). In patients undergoing D2 gastrectomy, the number of dissected lymph nodes in the N2 area was 16.3 ± 7.7 for RADG and 13.2 ± 5.3 for LADG (P = 0.001). The number of dissected lymph nodes around the splenic artery area was 2.9 ± 2.9 in RADG and 2.2 ± 2.0 in LADG (P = 0.04). Regarding postoperative complications, there was no statistically significant difference [five patients (5.7%) in RADG and 26 patients (9%) in LADG) (P = 0.330)].

CONCLUSION

RADG could provide an advantage over LADG in the dissection of the N2 area lymph nodes, especially around the splenic artery area.

Robotic surgery for gastric cancer

Laparoscopic gastrectomy is a widely used minimally invasive surgery for gastric cancer. However, skillful techniques are required to perform lymph node dissection using straight shaped forceps, particularly for D2 dissection. Robotic surgery using the da Vinci surgical system is anticipated to be a powerful tool for performing difficult techniques using high-resolution three-dimensional (3D) images and the EndoWrist equipped with seven degrees of freedom. Attempts are being made to apply robotic surgery in gastrectomy procedures mainly in Japan, South Korea, and Europe. Although definite superiority to laparoscopic gastrectomy is yet to be proven, robotic surgery has been reported to have a shorter learning curve and offer more precise dissection for total gastrectomy. Hence, its oncological efficacy needs to be verified in a clinical trial.

Robotic gastrectomy for gastric cancer

Robotic surgery for gastric cancer overcomes technical difficulties with laparoscopic gastrectomy. Its benefits include reduced intraoperative bleeding and shorter hospital stays; it is also easier to learn. Because accuracy increases during lymphadenectomy, a larger number of lymph nodes is likely to be retrieved using robotic gastrectomy. Higher costs and longer operation times have hindered the widespread adaptation and use of robotic surgery. In this review, we summarize the current status and issues regarding robotic gastrectomy.

Current status of robotic gastrectomy for gastric cancer

Although over 3000 da Vinci Surgical System (DVSS) devices have been installed worldwide, robotic surgery for gastric cancer has not yet become widely spread and is only available in several advanced institutions. This is because, at least in part, the advantages of robotic surgery for gastric cancer remain unclear. The safety and feasibility of robotic gastrectomy have been demonstrated in several retrospective studies. However, no sound evidence has been reported to support the superiority of a robotic approach for gastric cancer treatment. In addition, the long-term clinical outcomes following robotic gastrectomy have yet to be clarified. Nevertheless, a robotic approach can potentially overcome the disadvantages of conventional laparoscopic surgery if the advantageous functions of this technique are optimized, such as the use of wristed instruments, tremor filtering and high-resolution 3-D images. The potential advantages of robotic gastrectomy have been discussed in several retrospective studies, including the ability to achieve sufficient lymphadenectomy in the area of the splenic hilum, reductions in local complication rates and a shorter learning curve for the robotic approach compared to conventional laparoscopic gastrectomy. In this review, we present the current status and discuss issues regarding robotic gastrectomy for gastric cancer.

[Spectrum of laparoscopic surgery for gastric tumors]

Minimally invasive operative procedures are increasingly being used for treating tumors of the upper gastrointestinal tract. While minimally invasive surgery (MIS) has become established as a standard procedure for benign tumors and gastrointestinal stromal tumors (GIST) based on current studies, the significance of MIS in the field of gastric cancer is the topic of heated debate. Until now the majority of studies and meta-analyses on gastric cancer have come from Asia and these indicate the advantages of MIS in terms of intraoperative blood loss, minor surgical complications and swifter convalescence although without any benefits in terms of long-term oncological results and quality of life. Unlike in Germany, gastric cancer in Asia with its unchanged high incidence rate, 50 % frequency of early carcinoma and predominantly distal tumor localization is treated at high-volume centres. Due to the proven marginal advantages of MIS over open resection described in the published studies no general recommendation for laparoscopic surgery of gastric cancer can currently be given.

Robot-assisted gastrectomy for gastric cancer: current status and technical considerations

BACKGROUND

Robot-assisted gastrectomy has been reported as a safe alternative to the conventional laparoscopy or open approach for treating early gastric carcinoma. To date, however, there are a limited number of published reports available in the literature.

METHODS

We assess the current status of robotic surgery in the treatment of gastric cancer, focusing on the technical details and oncological considerations.

RESULTS

In gastric surgery, the biggest advantage of robotic surgery is the ease and reproducibility of D2-lymphadenectomy. Reports show that even the intracorporeal digestive restoration is facilitated by use of the robotic approach, particularly following total gastrectomy. Additionally, the accuracy of robotic dissection is confirmed by decreased blood loss, as reported in series comparing robot-assisted with laparoscopic gastrectomy. The learning curve and technical reproducibility also appear to be shorter with robotic surgery and, consequently, robotics can help to standardize and diffuse minimally invasive surgery in the treatment of gastric cancer, even in the later stages. This is important because the application of minimally invasive surgery is limited by the complexity of performing a D2-lymphadenectomy. The potential to reproduce D2-lymphadenectomy, enlarged resections, and complex reconstructions provides robotic surgery with an important role in the therapeutic strategy of advanced gastric cancer.

CONCLUSIONS

While published reports have shown no significant differences in surgical morbidity, mortality, or oncological adequacy between robot-assisted and conventional laparoscopic gastrectomy, more studies are needed to assess the indications and oncological effectiveness of robotic use in the treatment of gastric carcinoma. Herein, the authors assess the current status of robotic surgery in the treatment of gastric cancer, focusing on the technical details and oncological considerations.

Current status of minimally invasive surgery for gastric cancer: A literature review to highlight studies limits

BACKGROUND

Gastric cancer represents a great challenge for health care providers and requires a multidisciplinary approach in which surgery plays the main role. Minimally invasive surgery has been progressively developed, first with the advent of laparoscopy and more recently with the spread of robotic surgery, but a number of issues are currently being investigate, including the limitations in performing effective extended lymph node dissections and, in this context, the real advantages of using robotic systems, the possible role for advanced Gastric Cancer, the reproducibility of completely intracorporeal techniques and the oncological results achievable during follow-up.

METHOD

Searches of MEDLINE, Embase and Cochrane Central Register of Controlled Trials were performed to identify articles published until April 2014 which reported outcomes of surgical treatment for gastric cancer and that used minimally invasive surgical technology. Articles that deal with endoscopic technology were excluded.

RESULTS

A total of 362 articles were evaluated. After the review process, data in 115 articles were analyzed.

CONCLUSION

A multicenter study with a large number of patients is now needed to further investigate the safety and efficacy as well as long-term outcomes of robotic surgery, traditional laparoscopy and the open approach.

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

Health-related quality of life after robot-assisted distal gastrectomy in early gastric cancer

PURPOSE

This study was designed to assess the chronological change in health-related quality of life (HRQOL) following robot-assisted distal gastrectomy (RADG) for early gastric cancer (EGC) and to compare the HRQOL of the patients undergoing RADG with that of the general population.

METHODS

Patients undergoing RADG for EGC between March 2010 and May 2011 were enrolled. The European Organization for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30) and the gastric cancer-specific module (QLQ-STO22) were completed before the operation and at 1 week as well as 1, 3, 6, and 12 months postsurgery. HRQOL data of the enrolled patients were compared to reference values obtained from the general population.

RESULTS

A total of 30 patients were enrolled, and the overall compliance for questionnaire response was 94.4 %. The worst scores for most of the domains were observed at 1 week postsurgery and usually returned to baseline levels within 3 months, except for fatigue, dysphagia, pain, and eating restriction. Diarrhea was the only symptom that did not recovered after 1 year. Before surgery, patients reported significantly worse social function and financial difficulties compared to the general population, which persisted for 1 year postsurgery.

CONCLUSIONS

The immediate deterioration of HRQOL after RADG was restored to baseline levels within 3 months postsurgery in the majority of the patients. Robotic assistance might aid in the rapid recovery of global health status after surgery in EGC patients. Prolonged impairment in social function compared with the general population suggests that psychological support is necessary even for EGC patients.

Meta-analysis of the short-term outcomes of robotic-assisted compared to laparoscopic gastrectomy

OBJECTIVE

To compare the short-term outcomes of gastric cancer patients treated with robotic gastrectomy (RG) or laparoscopic gastrectomy (LG).

INTRODUCTION

Robotic gastrectomy (RG) has been used for gastric cancer since 2002. This meta-analysis evaluates the safety and efficacy of robotic gastrectomy (RG) and conventional laparoscopic gastrectomy (LG) for gastric cancer.

MATERIAL AND METHODS

Pubmed, Embase and The Cochrane Library were searched, and manual searches were performed up to March 31, 2013. Five non-randomized control trials that reported RG and LG for gastric cancer were included. Outcomes evaluated were operation time, number of retrieved LN, blood loss, the length of the resection margin, complications, length of postoperative hospital stay.

RESULTS

Of 1796 patients in five studies, 551 were allocated to RG and 1245 to LG. Operation time was significantly shorter in the latter group (weighted mean difference 42.9; 95 % confidence interval 20.87 to 64.92 min; p < 0.05). Blood loss weighted mean difference was -16.07 (95 % confidence interval -32.78 to 0.64 mL; p < 0.05) and postoperative stay weighted mean difference was -1.98 (95 % confidence interval -3.66 to -0.3 days; p < 0.05); both were less in the RG group. LN, length of the resection margin, and postoperative complications were similar in both groups.

CONCLUSION

It may be concluded that RG is a safe and comfortable alternative to LG and is justifiable in the light of clinical trials.

Robot-assisted vs laparoscopy-assisted gastrectomy for gastric cancer: A meta-analysis based on 3518 subjects

AIM: To compare the short-term clinical outcomes of robot-assisted gastrectomy (RAG) with laparoscopy-assisted gastrectomy (LAG) in gastric cancer patients.

METHODS: Articles were identified through a literature search of Pubmed, EMBASE, Scopus, Web of Science, Chinese National Knowledge Infrastructure and the Cochrane Library. Weighted mean differences (WMDs) and odds ratios (ORs) were selected as effect sizes for quantitative variables and qualitative variables, respectively. And 95%CIs were also calculated.

RESULTS: A total of 13 studies with 3518 patients were included. RAG was associated with longer operative time (WMD = 46.26 min, 95%CI: 31.89-60.63, P < 0.00001), less blood loss [WMD = -37.19 mL, 95%CI: -60.16-(-14.23), P = 0.002] and shorter postoperative hospital stay [WMD = -0.65 d, 95%CI: -1.24-(-0.05), P = 0.03] than LAG. No significant difference in the numbers of retrieved lymph nodes was found between the two groups (WMD = 1.46, 95%CI: -0.19-3.10, P = 0.08). There was no significant difference in mortality (OR = 1.55, 95%CI: 0.49-4.94, P = 0.45), overall complications (OR = 1.00, 95%CI: 0.80-1.26, P = 0.98), anastomosis leakage (OR = 1.02, 95%CI: 0.62-1.65, P = 0.95) and anastomosis stenosis rates (OR = 0.54, 95%CI: 0.18-1.57, P = 0.25).

CONCLUSION: RAG is effective and safe in the treatment of gastric cancer. RAG is a promising alternative to laparoscopic surgery. Long-term randomized controlled studies with large scale and improved designs are needed to further evaluate the long-term outcomes.

Efficacy evaluation of subtotal and total gastrectomies in robotic surgery for gastric cancer compared with that in open and laparoscopic resections: a meta-analysis

PURPOSES

Robotic gastrectomy (RG), as an innovation of minimally invasive surgical method, is developing rapidly for gastric cancer. But there is still no consensus on its comparative merit in either subtotal or total gastrectomy compared with laparoscopic and open resections.

METHODS

Literature searches of PubMed, Embase and Cochrane Library were performed. We combined the data of four studies for RG versus open gastrectomy (OG), and 11 studies for robotic RG versus laparoscopic gastrectomy (LG). Moreover, subgroup analyses of subtotal and total gastrectomies were performed in both RG vs. OG and RG vs. LG.

RESULTS

Totally 12 studies involving 8493 patients met the criteria. RG, similar with LG, significantly reduced the intraoperative blood loss than OG. But the duration of surgery is longer in RG than in both OG and LG. The number of lymph nodes retrieved in RG was close to that in OG and LG (WMD = -0.78 and 95% CI, -2.15-0.59; WMD = 0.63 and 95% CI, -2.24-3.51). And RG did not increase morbidity and mortality in comparison with OG and LG (OR = 0.92 and 95% CI, 0.69-1.23; OR = 0.72 and 95% CI, 0.25-2.06) and (OR = 1.06 and 95% CI, 0.84-1.34; OR = 1.55 and 95% CI, 0.49-4.94). Moreover, subgroup analysis of subtotal and total gastrectomies in both RG vs. OG and RG vs. LG revealed that the scope of surgical dissection was not a positive factor to influence the comparative results of RG vs. OG or LG in surgery time, blood loss, hospital stay, lymph node harvest, morbidity, and mortality.

CONCLUSIONS

This meta-analysis highlights that robotic gastrectomy may be a technically feasible alternative for gastric cancer because of its affirmative role in both subtotal and total gastrectomies compared with laparoscopic and open resections.

Meta-analysis of outcomes compared between robotic and laparoscopic gastrectomy for gastric cancer

This meta-analysis was performed to evaluate and compare the outcomes of robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) for treating gastric cancer. A systematic literature search was carried out using the PubMed database, Web of Knowledge, and the Cochrane Library database to obtain comparative studies assessing the safety and efficiency between RG and LG in May, 2013. Data of interest were analyzed by using of Review Manager version 5.2 software (Cochrane Collaboration). A fixed effects model or random effects model was applied according to heterogeneity. Seven papers reporting results that compared robotic gastrectomy with laparoscopic gastrectomy for gastric cancer were selected for this meta-analysis. Our meta- analysis included 2,235 patients with gastric cancer, of which 1,473 had undergone laparoscopic gastrectomy, and 762 had received robotic gastrectomy. Compared with laparoscopic gastrectomy, robotic gastrectomy was associated with longer operative time but less blood loss. There were no significant difference in terms of hospital stay, total postoperative complication rate, proximal margin, distal margin, numbers of harvested lymph nodes and mortality rate between robotic gastrectomy and laparoscopic gastrectomy. Our meta-analysis showed that robotic gastrectomy is a safe technique for treating gastric cancer that compares favorably with laparoscopic gastrectomy in short term outcomes. However, the long term outcomes between the two techniques need to be further examined.

Is laparoscopic total gastrectomy a safe operation? A review of various anastomotic techniques and their outcomes

Laparoscopic distal gastrectomy is an accepted option for gastric cancer surgery; however, laparoscopic total gastrectomy (LTG) is not widely performed. There is concern about the safety of the operation due to the difficulty of extracorporeal reconstruction through a mini-laparotomy. Efforts have been made to establish an intracorporeal anastomotic technique for esophagojejunostomy. This article reviews the current techniques available for laparoscopic esophagojejunostomy and their surgical outcomes. Several different techniques using either circular or linear staplers have been reported; however, the apparent superiority of any particular method has not been confirmed. The incidence of anastomosis-related complications varied among studies, but different techniques all successfully achieved excellent outcomes. The overall complication rate of LTG was similar to that of open total gastrectomy, suggesting that LTG is a safe and feasible option. However, the feasibility of LTG with D2 lymph node dissection for advanced upper gastric cancer needs to be confirmed in further studies, because most of the patients included in the LTG studies were diagnosed with early stages of disease.

Robot-assisted gastrectomy and oesophagectomy for cancer

BACKGROUND

Robot-assisted surgery is a technically feasible alternative to open and laparoscopic surgery, which is being more frequently used in general surgery. We undertook this review to investigate whether robotic assistance provides a significant benefit for oesophagogastric cancer surgery.

METHODS

Electronic databases were searched for original English-language publications for robotic-assisted gastrectomy and oesophagectomy between January 1990 and October 2013.

RESULTS

Sixty-one publications were included. Thirty-five included gastrectomy, 31 included oesophagectomy and five included both operations. Several publications suggest that robot-assisted subtotal gastrectomy can be as safe and effective as an open or laparoscopic procedure, with equal outcomes with regard to the number of lymph nodes resected, overall morbidity and perioperative mortality, and length of hospital stay. Robotic assistance is associated with longer operation times but also with less blood loss in some reports. A significant benefit for robotic assistance has not been shown for the more extensive operations of oesophagectomy or total gastrectomy with D2-lymphadenectomy. There are very few oncologic data regarding local recurrence or long-term survival for any of the robotic operations.

CONCLUSIONS

No significant differences in morbidity, mortality or number of lymph node harvested have been shown between robot-assisted and laparoscopic gastrectomy or oesophagectomy. Robotic surgery, with its relatively short learning curve, may facilitate reproducible minimally invasive surgery in this field but operation times are reportedly longer and cost differences remain unclear. Randomized trials with oncologic outcomes and cost comparisons are needed.

Brazilian consensus in gastric cancer: guidelines for gastric cancer in Brazil

BACKGROUND

In Brazil, gastric cancer is the fourth most common malignancy among men and sixth among women. The cause is multivariate and the risks are well known. It has prognosis and treatment defined by the location and staging of the tumor and number of lymph nodes resected and involved.

AIM

The Brazilian Consensus on Gastric Cancer promoted by ABCG was designed with the intention to issue guidelines that can guide medical professionals to care for patients with this disease.

METHODS

Were summarized and answered 43 questions reflecting consensus or not on diagnosis and treatment that may be used as guidance for its multidisciplinary approach. The method involved three steps. Initially, 56 digestive surgeons and related medical specialties met to formulate the questions that were sent to participants for answers on scientific evidence and personal experience. Summaries were presented, discussed and voted in plenary in two other meetings. They covered 53 questions involving: diagnosis and staging (six questions); surgical treatment (35 questions); chemotherapy and radiotherapy (seven questions) and anatomopathology, immunohistochemistry and perspective (five questions). It was considered consensus agreement on more than 70% of the votes in each item.

RESULTS

All the answers were presented and voted upon, and in 42 there was consensus.

CONCLUSION

It could be developed consensus on most issues that come with the care of patients with gastric cancer and they can be transformed in guidelines.

Systematic review and meta-analysis of robotic surgery compared with conventional laparoscopic and open resections for gastric carcinoma

BACKGROUND

Robot-assisted gastrectomy (RAG) has been developed in the hope of improving surgical quality and overcoming the limitations of conventional laparoscopically assisted gastrectomy (LAG) and open gastrectomy (OG) for gastric cancer. The aim of this study was to determine the extent of evidence in support of these ideals.

METHODS

A systematic review of the three operation types (RAG, LAG and OG) was carried out to evaluate short-term outcomes including duration of operation, retrieved lymph nodes, estimated blood loss, resection margin status, technical postoperative complications and hospital stay.

RESULTS

Nine non-randomized observational clinical studies involving 7200 patients satisfied the eligibility criteria. RAG was associated with longer operating times than LAG and OG (weighted mean difference 61.99 and 65.73 min respectively; P ≤ 0.001). The number of retrieved lymph nodes and the resection margin length in RAG were comparable with those of LAG and OG. Estimated blood loss as significantly less in RAG than in OG (P = 0.002), but not LAG. Mean hospital stay for RAG was similar to that for LAG (P = 0.14). In contrast, hospital stay was significantly shorter, by a mean of 2.18 days, for RAG compared with OG (P < 0.001). Postoperative complications were similar for all three operative approaches.

CONCLUSION

Short-term oncological outcomes of RAG were comparable with those of the other approaches. LAG was a shorter procedure and less expensive than RAG. Future studies involving RAG should focus on minimizing duration of operation and reducing cost.

Robotic gastrectomy versus laparoscopic gastrectomy for gastric cancer: comparison of surgical performance and short-term outcomes

PURPOSE

This study was designed to compare robot-assisted gastrectomy with laparoscopy-assisted gastrectomy in surgical performance and short-term clinical outcomes for gastric cancer and evaluate the safety and feasibility of robotic surgery.

METHODS

A retrospective database of patients who underwent robotic or laparoscopic gastrectomy for gastric cancer between March 2010 and May 2013 was examined. After screening, 514 patients who underwent gastrectomy for gastric cancer were enrolled in this study: 120 robotic and 394 laparoscopic surgery. Patient demographics, surgical performance, and short-term clinical outcomes were examined.

RESULTS

All operations were performed successfully. The clinicopathologic characteristics were similar between the two groups. Compared with the laparoscopic group, the robotic group had less intraoperative blood loss (118.3 ± 55.8 vs. 137.6 ± 61.6 ml, P < 0.001), more lymph nodes dissection (34.6 ± 10.9 vs. 32.7 ± 11.2, P = 0.013), and longer operation time (234.8 ± 42.4 vs. 221.3 ± 44.8 min, P = 0.003). The survival rates were 90.2% at 1 year, 78.1% at 2 years, and 67.8% at 3 years in the RAG group compared with 87.3% at 1 year, 77.1% at 2 years, and 69.9% at 3 years in the LAG group. The difference in overall survival rate between the two groups was not statistically significant (P = 0.812). In view of lymph node involvement, the 3-year survival rates for patients with negative nodal metastasis were 84.4% in the RAG group versus 82.6% in the LAG group (P = 0.972) and 57.5% in the RAG group versus 60.3% in the LADG group (P = 0.653) for those with positive nodal metastasis.

CONCLUSIONS

Comparing well with laparoscopic gastrectomy, robot-assisted gastrectomy is a feasible and safe surgical procedure with clear operation field, precise dissection, minimal trauma, and fast recovery. Longer follow-up time and randomized, clinical trials are needed to evaluate the clinical benefits and long-term oncological outcomes of this new technology.

Emerging Role of Robot-assisted Gastrectomy: Analysis of Consecutive 200 Cases

Purpose

Robotic surgery for gastric cancer is a promising alternative to laparoscopic surgery, but the data are limited. We aimed to evaluate whether gaining experience in robotic gastrectomy could improve surgical outcomes in the treatment of gastric cancer.

Materials and Methods

Two hundred and seven consecutive cases of patients with clinical stage I gastric cancer who underwent robotic surgery at the National Cancer Center of Korea between February 2009 and February 2012 were retrospectively reviewed. Surgical outcomes were analyzed and compared between the initial 100 and later 100 cases.

Results

Seven patients required conversion to open surgery and were excluded from further analysis. The mean operating time for all patients was 248.8 minutes, and mean length of hospitalization was 8.0 days. Twenty patients developed postoperative complications. Thirteen were managed conservatively, while 6 had major complications requiring invasive procedures. One mortality occurred owing to myocardial infarction. Operating time was significantly shorter in the latter 100 cases than in the initial 100 cases (269.9 versus 233.5 minutes, P<0.001). The number of retrieved lymph nodes was significantly greater in the latter cases (35.9 versus 39.9, P=0.032). The hospital stay of patients with complications was significantly longer in the initial cases than in the latter cases (16 versus 7 days, P=0.005).

Conclusions

Increased experience with the robotic procedure for gastric cancer was associated with improved outcomes, especially in operating time, lymph node retrieval, and shortened hospital stay of complicated patients. Further development of surgical techniques and technology might enhance the role of robotic surgery for gastric cancer.

Robot-assisted laparoscopic (RAL) surgery for gastric cancer

BACKGROUND

This literature review focuses on the potential benefits and eventual limitations of robotic surgery with respect to the traditional minimally invasive laparoscopic surgical technique for gastric cancer.

METHODS

A literature survey was performed using specific search phrases in PubMed. Series including < 10 cases and series including only an 'open group' of patients in comparison with the 'robotic group' were excluded. Characteristics such as patient demographics, perioperative outcomes and oncological results were analysed.

RESULTS

According to the analysis of 12 series, robotic gastric surgery has been shown to be a safe and feasible method. However, a considerable number of studies are composed of early-stage gastric cancer cases and there seems to be a lack of randomized controlled studies.

CONCLUSIONS

Large prospective randomized studies are still required in order to demonstrate the exact benefits of robotic surgery and its effects on survival in gastric cancer.

Comparison of short-term clinical outcomes between robotic and laparoscopic gastrectomy for gastric cancer: a meta-analysis of 2495 patients

BACKGROUND

Laparoscopic gastrectomy (LG) is being increasingly used to treat gastric cancer. However, there are still several technical disadvantages limiting its use. Robotic gastrectomy (RG) is an emerging minimally invasive technique that overcomes some of these limitations. This study compares RG with LG in the treatment of gastric cancer by performing a systematic review and meta-analysis of all published literature.

MATERIALS AND METHODS

Comparative studies published between January 1991 and April 2013 in the major databases were systematically searched. Evaluated end points were operative, postoperative, and oncological outcomes. Pooled odds ratios and weighted mean differences with 95% confidence intervals were calculated using either the fixed-effects model or random-effects model.

RESULTS

Nine nonrandomized comparative studies with 2495 patients were included, of which 736 procedures were robotic and 1759 were laparoscopic. RG was associated with a lower intraoperative blood loss and a shorter time to oral intake compared with LG. However, it was associated with a significantly longer operative time and shorter distal resection margin. In addition, there was no significant difference in the number of retrieved lymph nodes, proximal resection margin, rate of conversion to open surgery, overall morbidity, anastomotic leakage, anastomotic stenosis, intestinal obstruction, time to first flatus, length of hospital stay, and perioperative mortality rates between the two groups.

CONCLUSIONS

RG is comparable to LG, with respect to safety, technical feasibility, and oncological effectiveness in the treatment of gastric cancer. However, there is a need for well-designed prospective randomized controlled studies comparing the two procedures with long-term follow-up, to inform future practice.

Robotic versus Laparoscopic versus Open Gastrectomy: A Meta-Analysis

PURPOSE

To define the role of robotic gastrectomy for the treatment of gastric cancer, the present systematic review with meta-analysis was performed.

MATERIALS AND METHODS

A comprehensive search up to July 2012 was conducted on PubMed, EMBASE, and the Cochrane Library. All eligible studies comparing robotic gastrectomy versus laparoscopic gastrectomy or open gastrectomy were included.

RESULTS

Included in our meta-analysis were seven studies of 1,967 patients that compared robotic (n=404) with open (n=718) or laparoscopic (n=845) gastrectomy. In the complete analysis, a shorter hospital stay was noted with robotic gastrectomy than with open gastrectomy (weighted mean difference: -2.92, 95% confidence interval: -4.94 to -0.89, P=0.005). Additionally, there was a significant reduction in intraoperative blood loss with robotic gastrectomy compared with laparoscopic gastrectomy (weighted mean difference: -35.53, 95% confidence interval: -66.98 to -4.09, P=0.03). These advantages were at the price of a significantly prolonged operative time for both robotic gastrectomy versus laparoscopic gastrectomy (weighted mean difference: 63.70, 95% confidence interval: 44.22 to 83.17, P<0.00001) and robotic gastrectomy versus open gastrectomy (weighted mean difference: 95.83, 95% confidence interval: 54.48 to 137.18, P<0.00001). Analysis of the number of lymph nodes retrieved and overall complication rates revealed that these outcomes did not differ significantly between the groups.

CONCLUSIONS

Robotic gastrectomy for gastric cancer reduces intraoperative blood loss and the postoperative hospital length of stay compared with laparoscopic gastrectomy and open gastrectomy at a cost of a longer operating time. Robotic gastrectomy also provides an oncologically adequate lymphadenectomy. Additional high-quality prospective studies are recommended to better evaluate both short and long-term outcomes.

Minimally invasive surgery for gastric cancer

The interest in minimally invasive surgery (MIS) has rapidly increased in recent decades and surgeons have adopted minimally invasive techniques due to its reduced invasiveness and numerous advantages for patients. With increased surgical experience and newly developed surgical instruments, MIS has become the preferred approach not only for benign disease but also for oncologic surgery. Recently, robotic systems have been developed to overcome difficulties of standard laparoscopic instruments during complex procedures. Its advantages including three-dimensional images, tremor filtering, motion scaling, articulated instruments, and stable retraction have created the opportunity to use robotic technology in many procedures including cancer surgery. Gastric cancer is one of the most common causes of cancer-related deaths worldwide. While its overall incidence has decreased worldwide, the proportion of early gastric cancer has increased mainly in eastern countries following mass screening programs. The shift in the paradigm of gastric cancer treatment is toward less invasive approaches in order to improve the patient's quality of life while adhering to oncological principles. In this review, we aimed to summarize the operative strategy and current literature in laparoscopic and robotic surgery for gastric cancer.

Robotic gastric resection of large gastrointestinal stromal tumors

BACKGROUND

The stomach is the most common site for gastrointestinal stromal tumors (GIST) development. Surgical treatment consists of excision of the entire neoplastic mass, with sufficient surgical margins within healthy tissue. This can be achieved with different techniques ranging from wedge resections, typical gastric resections, right up to total gastrectomy. There aren't clear guidelines for the use of minimally invasive approach.

MATERIALS AND METHODS

From January 2011 to April 2012, 5 patients with presumed preoperative diagnosis of GIST were treated by robotic surgery at the Unit of Surgery and Advanced Oncologic Therapies, Forlì Hospital, Forlì, Italy. We report operative techniques, perioperative outcomes and follow-up.

RESULTS

Lesions were localized at anterior wall of gastric antrum (N = 2) and near pyloric area (N = 3). Mean tumor size was 5 cm (range 4-7 cm). Surgical procedures were 5 distal gastrectomy. None intervention was converted to open surgery and there weren't major intraoperative complications. Median operative time was 240 min (range 210-300 min) and mean intraoperative blood loss was 96 ml (80-120 ml). All lesions had microscopically negative resection margins. Median follow-up was 13.5 months (range 12-15 months) with a disease-free survival rate of 100%.

CONCLUSIONS

Surgical robotic approach for large GISTs is feasibility and new evidences are needed to clarify the effective role of different surgical strategies.

Early gastric cancer and dysplasia

Since the concept of early gastric cancer was first described in Japan in 1962, its treatment has evolved from curative surgical resection to endoscopic resection, initially with polypectomy to more recently with endoscopic submucosal dissection. As worldwide experience with these endoscopic techniques evolve and gain acceptance, studies have confirmed its comparable effectiveness with historical surgical outcomes in carefully selected patients. The criteria for endoscopic resection have expanded to offer more patients improved quality of life, avoiding the morbidity and mortality associated with surgery. This article summarizes the evolutional role of endoscopic and surgical therapy in early gastric cancer.

Laparoscopic gastrectomy for cancer

Gastric cancer is common worldwide. Tumor location and disease stage differ between Asian and Western countries. Western patients often have higher BMIs and comorbidities that may make laparoscopic resections challenging. Multiple trials from Asian countries demonstrate the benefits of laparoscopic gastrectomy for early gastric cancer while maintaining equivalent short-term and long-term oncologic outcomes compared with open surgery. The outcomes of laparoscopy seem to offer equivalent results to open surgery. In the United States, laparoscopic gastrectomy remains in its infancy and is somewhat controversial. This article summarizes the literature on the epidemiology, operative considerations and approaches, and outcomes for laparoscopic gastrectomy.

Robot versus laparoscopic gastrectomy for cancer by an experienced surgeon: comparisons of surgery, complications, and surgical stress

BACKGROUND

No previous robotic studies present an equivalent surgical quality comparison in an experienced setting for gastric cancer. In addition, a reliable postoperative complication assessment is needed to accurately evaluate surgical outcomes.

METHODS

After 20 cases of robotic-assisted gastrectomy (RAG), a total of 121 consecutive gastric cancer patients underwent gastrectomy (38 RAG vs 83 laparoscopic-assisted gastrectomy [LAG]) from February 2009 to November 2010 at the Department of Surgery, Korea University Anam Hospital, Seoul, Korea. The Clavien-Dindo (C-D) classification was used to classify surgical complications. The granulocyte-to-lymphocyte (G:L) ratio was analyzed to evaluate surgical stress.

RESULTS

The baseline characteristics, with the exception of age, were similar. The mean total operation time for RAG (234.4 ± 48.0 min) was not significantly different than that for LAG (220.0 ± 60.6 min; P = 0.198). However, in obese patients, fewer lymph nodes were harvested by RAG (23.4 ± 7.0) than by LAG (32.2 ± 12.5, P = 0.006). Overall C-D complications were more common for RAG (47.3 vs 38.5 %), but the difference was not significant (P = 0.361). The mean hospital stay was similar for the 2 groups. Surgical stress as estimated by the G:L ratio was comparable between the 2 groups.

CONCLUSIONS

RAG performed by an experienced surgeon resulted in similar postoperative outcomes and complications to those of LAG. Assessment of operation time, C-D complication grade, and G:L ratio revealed that RAG is a practical and feasible alternative to LAG, with the possible exception of obese patients.

Robotic gastrectomy: the current state of the art

Since the first laparoscopic gastrectomy for cancer was reported in 1994, minimally invasive surgery is enjoying its wide acceptance. Numerous procedures of this approach have developed, and many patients have benefited from its effectiveness, which has been recently demonstrated for early gastric cancer. However, since laparoscopic surgery is not exempt from some limitations, the robotic surgery system was introduced as a solution by the late 1990's. Many experienced surgeons have embraced this new emerging method that provides undoubted technical and minimally invasive advantages. To date, several studies have concentrated to this new system, and have compared it with open and laparoscopic approach. Most of them have reported satisfactory results concerning the post-operative short-term outcomes, but almost all believe that the role of robotic gastrectomy is still out of focus, especially because long-term outcomes that can prove robotic oncologic equivalency are lacking, and operative costs and time are higher in comparison to the open and laparoscopic ones. This article is a review about the current status of robotic surgery for the treatment of gastric cancer, especially, focusing on the technical aspects, comparisons to other approaches and future prospects.