Robotically-enhanced surgical anatomy enables surgeons to perform distal gastrectomy for gastric cancer using electric cautery devices alone. Surg Endosc. 2014;28:1180-1187. [PMID: 24202713 DOI: 10.1007/s00464-013-3304-x]

Clinical outcomes of robotic and laparoscopic gastrectomy using propensity score matching method: Data of 5-year period in a Korean high-volume gastric cancer center

INTRODUCTION

Despite the theoretical advantages of Robotic gastrectomy (RG) over laparoscopic gastrectomy (LG), the benefit of RG compared to LG remains controversial. To address this controversy, we evaluated the outcomes of RG compared to LG in the high-volume gastric cancer center.

MATERIALS AND METHODS

This single-center retrospective cohort study enrolled patients of RG and LG from January 2013 to December 2017 using propensity score matching. Results of operation, and overall survival were analyzed.

RESULTS

For RG, 268 patients were enrolled, and 733 patients with LG were matched. The four gastric methods were matched at the following ratios; Distal gastrectomy (RG: 35.8 % vs LG: 38.7 %), Total gastrectomy (RG: 16.0 % vs LG: 13.9 %), Pylorus-preserving gastrectomy (RG: 46.3 % vs LG: 44.7 %), Proximal gastrectomy (RG: 1.9 % vs LG: 2.6 %) The median number of retrieved lymph nodes (RG: 36.0 vs LG: 37.0, p = 0.247) and supra-pancreatic lymph nodes (RG: 8.0 vs LG: 7.0, p = 0.647), showed no difference. No difference was observed in complications (RG: 21.3 % vs LG: 21.4 %, p = 1.000), and severe complications (RG: 13.1 % vs LG: 12.7 %, p = 0.961) The 5-year overall survival was not significantly different (RG: 94.8 % vs LG: 93.1 %, hazard ratio: 0.76, 95 % confidence interval: 0.41-1.40, p = 0.379).

CONCLUSION

Our study observed no advantage in RG compared to LG regarding short-term and oncologic outcomes. To take advantage of RG, developing new articulating efficient devices would be necessary.

Evaluating the Role of Robotic Surgery Gastric Cancer Treatment: A Comprehensive Review by the Robotic Global Surgical Society (TROGSS) and European Federation International Society for Digestive Surgery (EFISDS) Joint Working Group

INTRODUCTION

Robot-assisted minimally invasive gastrectomy (RAMIG) represents a significant advancement in the surgical management of gastric cancer, offering superior dexterity, enhanced visualization, and improved ergonomics compared to laparoscopic gastrectomy (LG). This review systematically evaluates the current evidence on perioperative outcomes, oncological efficacy, learning curves, and economic considerations, providing insights into RAMIG's potential role in modern gastric cancer surgery.

METHODS

A thorough analysis of retrospective, prospective, and meta-analytic studies was conducted to compare RAMIG with LG. Key outcomes, including operative time, intraoperative blood loss, lymph node retrieval, postoperative complications, learning curve duration, and cost-effectiveness, were assessed. Emphasis was placed on both short-term and long-term oncological outcomes to determine the clinical value of RAMIG.

RESULTS

Evidence indicates that RAMIG is associated with reduced intraoperative blood loss, lower morbidity rates, and a shorter learning curve, with proficiency achieved after 11-25 cases compared to 40-60 cases for LG. The robotic platform's articulated instruments and enhanced three-dimensional visualization enable more precise lymphadenectomy, particularly in complex anatomical regions. Despite these advantages, operative time remains longer, and costs remain higher due to system acquisition, maintenance, and consumable expenses. However, emerging data suggest a gradual narrowing of cost disparities. While short-term outcomes are favorable, further high-quality, multicenter studies are needed to validate long-term oncological efficacy and survival outcomes.

CONCLUSION

RAMIG offers significant technical and clinical advantages over conventional LG, particularly in terms of precision and learning efficiency. However, the long-term oncological benefits and economic feasibility require further validation. Future research should focus on cost optimization, advanced technological integration such as near-infrared fluorescence and artificial intelligence, and multicenter trials to solidify RAMIG's role as a standard approach for gastric cancer surgery.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Korean Practice Guidelines for Gastric Cancer 2024: An Evidence-based, Multidisciplinary Approach (Update of 2022 Guideline)

Gastric cancer is one of the most common cancers in both Korea and worldwide. Since 2004, the Korean Practice Guidelines for Gastric Cancer have been regularly updated, with the 4th edition published in 2022. The 4th edition was the result of a collaborative work by an interdisciplinary team, including experts in gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology, and guideline development methodology. The current guideline is the 5th version, an updated version of the 4th edition. In this guideline, 6 key questions (KQs) were updated or proposed after a collaborative review by the working group, and 7 statements were developed, or revised, or discussed based on a systematic review using the MEDLINE, Embase, Cochrane Library, and KoreaMed database. Over the past 2 years, there have been significant changes in systemic treatment, leading to major updates and revisions focused on this area. Additionally, minor modifications have been made in other sections, incorporating recent research findings. The level of evidence and grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation system. Key factors for recommendation included the level of evidence, benefit, harm, and clinical applicability. The working group reviewed and discussed the recommendations to reach a consensus. The structure of this guideline remains similar to the 2022 version. Earlier sections cover general considerations, such as screening, diagnosis, and staging of endoscopy, pathology, radiology, and nuclear medicine. In the latter sections, statements are provided for each KQ based on clinical evidence, with flowcharts supporting these statements through meta-analysis and references. This multidisciplinary, evidence-based gastric cancer guideline aims to support clinicians in providing optimal care for gastric cancer patients.

Robotic vs laparoscopic distal gastrectomy with Billroth I and II reconstruction: a systematic review and meta-analysis

Robotic distal gastrectomy (RDG) has been increasingly used for the treatment of gastric cancer, however, its comparative safety and efficacy against the laparoscopic approach (LDG), remains unclear, especially when accounting the reconstruction method as a confounder. This systematic review and meta-analysis aims to evaluate the short-term outcomes of RDG vs LDG In patIents with gastric cancer, undergoing Billroth I and II reconstruction. A systematic review was conducted in accordance with PRISMA guidelines. We searched Pubmed, Scopus and the Cochrane Library, up to October 22nd, 2024. The primary outcomes analyzed were the blood loss, operative duration, and the number of harvested lymph nodes and the secondary outcomes included overall complications, time to oral intake, duration of hospitalization and time to first flatus. Random-effects models were used to calculate weighted mean differences (WMD) and Odds ratios (OR) with 95% confidence intervals (CI), and heterogeneity was assessed using the I2 statistic. P values were also calculated. Sensitivity analysis was performed for outcomes with moderate to high heterogeneity. Five studies were included, involving 811 patients (RDG: n = 289, LDG: n = 522). RDG was associated with a significantly longer operative duration compared to LDG (WMD = 34.14 min, 95%CI 10.92 to 57.35, P = 0.004, I2 = 91%). RDG patients initiated oral intake earlier (WMD = -0.20 days, 95%CI -0.39 to -0.01, P = 0.03, I2 = 45%). RDG resulted in shorter hospital stays (WMD = -1.48 days, 95%CI -2.91 to -0.04, P = 0.04, I2 = 86%). RDG patients had a faster return to bowel function (time to first flatus) (WMD = -0.33 days, 95%CI -0.50 to -0.15, P = 0.00003, I2 = 57%). No statistically significant differences were observed regarding blood loss between RDG and LDG (WMD = -3.88 mL, 95%CI -21.63 to 13.87, P = 0.67, I2 = 78%). There was no statistically significant difference in complication rates (OR = 0.61, 95%CI 0.36 to 1.03, P = 0.06, I2 = 0%). No significant differences were observed regarding the number of lymph nodes harvested (WMD = -0.49, 95%CI -3.02 to 2.04, P = 0.70, I2 = 24%). Sensitivity analysis confirmed the robustness of the findings of operative duration and time to first flatus. RDG with BI/ BII requires longer operative duration, but it associated with faster recovery compared to LDG. No differences were observed between RDG and LDG with regards to overall complications, number of harvested lymph nodes and blood loss, showing that RDG is as safe and oncological equivalent to LDG. Future studies particularly, multi-center randomized clinical trials, should have a longer follow up period and examine the type of reconstruction separately. PROSPERO registration: CRD42024605895.

Introduction of a new surgical robot platform "hinotori™" in an institution with established da Vinci surgery™ for digestive organ operations

BACKGROUND

New platforms for robotic surgery have recently become available for clinical use; however, information on the introduction of new surgical robotic platforms compared with the da Vinci™ surgical system is lacking. In this study, we retrospectively determined the safe introduction of the new "hinotori™" surgical robot in an institution with established da Vinci surgery using four representative digestive organ operations.

METHODS

Sixty-one patients underwent robotic esophageal, gastric, rectal, and pancreatic operations using the hinotori system in our department in 2023. Among these, 22 patients with McKeown esophagectomy, 12 with distal gastrectomy, 11 with high- and low-anterior resection of the rectum, and eight with distal pancreatectomy procedures performed by hinotori were compared with historical controls treated using da Vinci surgery.

RESULTS

The console (cockpit) operation time for distal gastrectomy and rectal surgery was shorter in the hinotori group compared with the da Vinci procedure, and there were no significant differences in the console times for the other two operations. Other surgical results were almost similar between the two robot surgical groups. Notably, the console times for hinotori surgeries showed no significant learning curves, determined by the cumulative sum method, for any of the operations, with similar values to the late phase of da Vinci surgery.

CONCLUSIONS

This study suggests that no additional learning curve might be required to achieve proficient surgical outcomes using the new hinotori surgical robotic platform, compared with the established da Vinci surgery.

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

Distal gastrectomy (DG) with lymph node dissection for gastric cancer is routinely performed. In this meta-analysis, we present an updated overview of the perioperative and oncological outcomes of laparoscopic DG (LDG) and robotic DG (RDG) to compare their safety and overall outcomes in patients undergoing DG. An extensive search was conducted using the MEDLINE, EMBASE, PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials from the establishment of the database to June 2023 for randomized clinical trials comparing RDG and LDG. The primary outcome was operative results, postoperative recovery, complications, adequacy of resection, and long-term survival. We identified twenty studies, evaluating 5,447 patients (1,968 and 3,479 patients treated with RDG and LDG, respectively). We observed no significant differences between the two groups in terms of the proximal resection margin, number of dissected lymph nodes, major complications, anastomosis site leakage, time to first flatus, and length of hospital stay. The RDG group had a longer operative time (P < 0.00001), lesser bleeding (P = 0.0001), longer distal resection margin (P = 0.02), earlier time to oral intake (P = 0.02), fewer overall complications (P = 0.004), and higher costs (P < 0.0001) than the LDG group. RDG is a promising approach for improving LDG owing to acceptable complications and the possibility of radical resection. Longer operative times and higher costs should not prevent researchers from exploring new applications of robotic surgery.

Safety and feasibility of reduced-port robotic distal gastrectomy for gastric cancer: a phase I/II clinical trial using the da Vinci Single Port(SP) robotic system

Minimally invasive surgery reduces surgical trauma and the size and number of incisions. The da Vinci SP robotic surgical system was designed to overcome the technical demands of single-incision laparoscopic surgery. This study aimed to demonstrate the safety and feasibility of single-port (SP) robotic distal gastrectomy (SPRDG) for patients with gastric cancer using the da Vinci SP system (Intuitive Surgical Inc., Sunnyvale, CA, USA). This study was designed as a single-arm prospective phase I/II clinical trial of SPRDG (first posted date: 21/09/2021, NCT05051670; clinicaltrials.gov). SPRDG using the da Vinci SP system was performed on 19 patients with gastric cancer between December 2021 and October 2022. The primary outcome was the safety of SPRDG as measured by major postoperative complications. The secondary outcomes were operation time, bleeding amount, bowel motility recovery, and length of hospital stay. SPRDG was performed in all 19 patients without unexpected events, such as use of additional trocars or conversion to laparoscopic or open surgery. No major complications occurred postoperatively (0/19, 0.0%). The mean operation time was 218 min (range 164-286 min). The mean hospital stay duration was 3.2 days (range 2-4 days). This phase I/II clinical trial, performed by a single expert surgeon, demonstrated the safety and feasibility of SPRDG with the da Vinci SP system in selected patients with gastric cancer. SPRDG could be a reasonable alternative to conventional or reduced-port minimally invasive gastrectomy, as it has cosmetic advantages, early recovery, and safe discharge.

Application of artificial intelligence for improving early detection and prediction of therapeutic outcomes for gastric cancer in the era of precision oncology

Gastric cancer is a leading contributor to cancer incidence and mortality globally. Recently, artificial intelligence approaches, particularly machine learning and deep learning, are rapidly reshaping the full spectrum of clinical management for gastric cancer. Machine learning is formed from computers running repeated iterative models for progressively improving performance on a particular task. Deep learning is a subtype of machine learning on the basis of multilayered neural networks inspired by the human brain. This review summarizes the application of artificial intelligence algorithms to multi-dimensional data including clinical and follow-up information, conventional images (endoscope, histopathology, and computed tomography (CT)), molecular biomarkers, etc. to improve the risk surveillance of gastric cancer with established risk factors; the accuracy of diagnosis, and survival prediction among established gastric cancer patients; and the prediction of treatment outcomes for assisting clinical decision making. Therefore, artificial intelligence makes a profound impact on almost all aspects of gastric cancer from improving diagnosis to precision medicine. Despite this, most established artificial intelligence-based models are in a research-based format and often have limited value in real-world clinical practice. With the increasing adoption of artificial intelligence in clinical use, we anticipate the arrival of artificial intelligence-powered gastric cancer care.

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.

Solo surgery in robot-assisted gastrectomy versus laparoscopic gastrectomy for gastric cancer: a propensity score-matched analysis

BACKGROUND

Robot-assisted gastrectomy (RG) for gastric cancer is still not well standardized. This study aimed to explore the feasibility and effectiveness of solo surgery in robot-assisted gastrectomy (SRG) for gastric cancer compared to laparoscopic gastrectomy (LG).

METHODS

This was a single-center retrospective comparative study between SRG and conventional LG. Between April 2015 and December 2022, 510 patients underwent gastrectomy, and data from a prospectively collected database were analyzed. We identified 372 patients who underwent LG (n = 267) and SRG (n = 105) and the remaining 138 patients were excluded because of remnant gastric cancer, esophagogastric junction cancer, open gastrectomy, concurrent surgery for concomitant malignancies, RG before starting SRG, or cases in which the author was unable to perform or supervise gastrectomy. Propensity score matching was performed at a ratio of 1:1 to reduce bias from confounding patient-related variables, and short-term outcomes were compared between the groups.

RESULTS

After propensity score matching, 90 pairs of patients who underwent LG and SRG were selected. In the propensity-matched cohort, the operation time was significantly shorter in the SRG group than that in the LG group (SRG = 305.7 ± 74.0 min vs. LG = 340.3 ± 91.65 min, p < 0.0058), less estimated blood loss was observed in the SRG group than that in the LG group (SRG = 25.6 ± 50.6 mL vs. LG = 76.1 ± 104.2 mL, p < 0.0001) and postoperative hospital stay was shorter in the SRG group than that in the LG group (SRG = 7.1 ± 0.8 days vs. LG = 9.1 ± 7.7 days, p = 0.015).

CONCLUSION

We found that SRG for gastric cancer was technically feasible and effective with favorable short-term outcomes, including shorter operative time, less estimated blood loss, shorter hospital stays, and lower postoperative morbidity than those in LG.

Secure Robotic Transthoracic Valvuloplastic Esophagogastrostomy by Double Flap Technique in Esophagogastric Junctional Cancer Surgery

Valvuloplastic esophagogastrostomy by the double flap technique (VPEG-DFT) after proximal gastrectomy for early proximal gastric cancer or esophagogastric junctional cancer (EGJC) is a promising procedure to prevent reflux. However, the transhiatal procedure alone for alimentary reconstruction is sometimes too complex because of the short esophageal remnant. Therefore, additional transthoracic procedures are needed in some patients with EGJC. Although additional thoracoscopic surgery has been reported, no reports to date have described robotic transthoracic VPEG-DFT after excision of EGJC. We herein describe the secure robotic techniques of transthoracic VPEG-DFT performed in 3 patients with EGJC. After completion of the abdominal procedures by robotic and extracorporeal creation of H -shaped flaps on the gastric remnant, robotic VPEG-DFT through the right thoracic approach was performed in the prone position. To accomplish VPEG-DFT in the thorax of patients in the prone position, fixation of the esophagus and stomach was performed before the rotation of the 2 organs to expose the planned anastomotic aspect. In addition, the final abdominal phase was required again to prevent a postoperative hiatal hernia. Secure techniques of right transthoracic VPEG-DFT by robotic surgery could contribute to the successful treatment of EGJC when the remnant esophagus is too short.

Perioperative outcomes of robotic versus laparoscopic distal gastrectomy for gastric cancer: a meta-analysis of propensity score-matched studies and randomized controlled trials

Background

Da Vinci robotic surgery system, a novel type of surgery, was widespread in surgical field. However, the perioperative outcomes of robotic distal gastrectomy (RDG) are still controversy, despite several observational studies and randomized controlled trials (RCT) had been reported. Therefore, we performed a meta-analysis of propensity score-matched (PSM) and RCT studies to evaluated the perioperative feasibility and safety of RDG.

Methods

Studies were systematically searched in PubMed, Web of Science, Cochrane Library, and Embase database, and screened according to the defined limitations. The quality of PSM studies and RCT studies were respectively assessed by ROBINS-I and Cochrane risk-of-bias tool. Extracted data were analyzed by Review Manager 5.4.

Results

7 PSM studies and 1 RCT with a total of 2763 patients were included in this analysis. The longer operative time (MD = 31.42, 95% CI [22.88, 39.96], p < 0.00001), less blood loss (MD = − 25.89, 95% CI [− 36.18, − 15.6], p < 0.00001), more retrieved lymph nodes (MD = 3.46, 95% CI [2.94, 3.98], p < 0.00001), shorter time to first flatus (MD = − 0.08, 95% CI [− 0.13, − 0.02], p = 0.006) and liquid intake (MD = − 0.13, 95% CI [− 0.22, − 0.05], p = 0.002) were observed in RDG group compared with LDG group. There are no statistically significant in time to start soft diet, postoperative hospital stays, overall complications, complications Grade I–II, complications Grade ≥ III, anastomotic leakage, bleeding, intra-abdominal bleeding, intraluminal bleeding, ileus, abdominal infection, delayed gastric emptying and wound complications.

Conclusions

RDG showed less blood loss and more retrieved lymph nodes, revealed less time to first flatus and liquid intake after operation. But the operative time was longer in RDG group than in LDG. The incidence rate of postoperative complications was comparable between RDG and LDG.

Robotic spleen-preserving total gastrectomy shows better short-term advantages: a comparative study with laparoscopic surgery

BACKGROUND

Robotic surgery may be advantageous for complex surgery. We aimed to compare the intraoperative and postoperative short-term outcomes of spleen-preserving splenic hilar lymphadenectomy (SPSHL) during robotic and laparoscopic total gastrectomy.

METHODS

From July 2016 to December 2020, the clinicopathological data of 115 patients who underwent robotic total gastrectomy combined with robotic SPSHL (RSPSHL) and 697 patients who underwent laparoscopic total gastrectomy combined with laparoscopic SPSHL (LSPSHL) were retrospectively analyzed. A 1:2 ratio propensity score matching (PSM) was used to balance the differences between the two groups to compare their outcomes. The Generic Error Rating Tool was used to evaluate the technical performance.

RESULTS

After PSM, the baseline preoperative characteristics of the 115 patients in the RSPSHL and 230 patients in the LSPSHL groups were balanced. The dissection time of the region of the splenic artery trunk (5.4 ± 1.9 min vs. 7.8 ± 3.6 min, P < 0.001), the estimated blood loss during SPSHL (9.6 ± 4.8 ml vs. 14.9 ± 7.8 ml, P < 0.001), and the average number of intraoperative technical errors during SPSHL (15.1 ± 3.4 times/case vs. 20.7 ± 4.3 times/case, P < 0.001) were significantly lower in the RSPSHL group than in the LSPSHL group. The RSPSHL group showed higher dissection rates of No. 10 (78.3% vs. 70.0%, P = 0.104) and No. 11d (54.8% vs. 40.4%, P = 0.012) lymph nodes and significantly improved postoperative recovery results in terms of times to ambulation, first flatus, and first intake (P < 0.05). The splenectomy rates of the two groups were similar (1.7% vs. 0.4%, P = 0.539), and there was no significant difference in morbidity and mortality within postoperative 30 days (13.0% vs. 15.2%, P = 0.589).

CONCLUSION

Compared to LSPSHL, RSPSHL has more advantages in terms of surgical qualities and postoperative recovery process with similar morbidity and mortality. For complex SPSHL, robotic surgery may be a better choice.

Robotic radical distal gastrectomy for gastric cancer using the soft coagulation scissors technique

We have developed a novel technique for safe and precise lymph-node dissection during robotic gastrectomy for gastric cancer using monopolar curved scissors with soft coagulation. This technique is called the soft coagulation scissors technique. The technical details of this technique are as follows: a long bipolar grasper in the first arm and monopolar curved scissors in the third arm are primarily used for lymph-node dissection, maximizing the use of the robotic arm articulation. The monopolar curved scissors were energized in the soft coagulation mode of the Valleylab™ FT10 energy platform or in the forced coagulation mode of the ERBE VIO^®dV with an effect 1/power limit of 15 W. This limit was confirmed to be equivalent to the soft coagulation mode in preliminary experiments, and a long bipolar grasper applied adequate tension to the surgical site without strongly grasping the tissue or applying traction. The peak temperatures of our devices were more than 100 °C lower than those of the Harmonic ACE and the Maryland bipolar forceps with the forced coagulation mode. Overall, 80 patients with gastric cancer, including 36 (45.0%) with stage III or IV cancers, underwent robotic distal gastrectomy with this technique. The median estimated blood loss was 10 g. There were only four surgical complications (5.0%): two paralytic ileus, one intra-abdominal abscess, and one duodenal stump leakage. Robotic distal gastrectomy for gastric cancer is made possible by the soft coagulation scissors technique, which allows for safe and precise lymph-node dissection.

Surgical invasiveness and lymphadenectomy in robotic and laparoscopic gastrectomy: A retrospective study with propensity-score matching

BACKGROUND

There is no consensus amongst comparative studies about the advantages of robotic over laparoscopic surgeries for gastric cancer (GC). We compared invasiveness and lymph node dissection between robotic and laparoscopic gastrectomies (RG and LG).

METHODS

We retrospectively reviewed the medical records of 215 consecutive patients with GC who underwent RG or LG with lymphadenectomy from January 2011-December 2020. Propensity score matching analysis was performed to control selection bias.

RESULTS

The RG group had less operative blood loss (P = 0.0005) and higher C-reactive protein levels on postoperative day 1 (P = 0.0006) than the LG group. When analyzing the specific sites of dissected lymph nodes, station groups of supra-pancreatic and lesser curvature areas accounted for this difference (P = 0.0073 and 0.0362, respectively).

CONCLUSIONS

RG demonstrated lesser intraoperative bleeding, less of a postoperative inflammatory response, and a higher proportion of lymph node removal than LG, suggesting that it is a better surgical and oncological procedure.

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.

Advantages of a robotic approach compared with laparoscopy gastrectomy for patients with high visceral fat area

BACKGROUND

Gastric cancer surgery for obese patients is regarded as a technically challenging procedure. The morbidity after gastrectomy has been reported to be significantly higher in patients with high visceral fat area (VFA). Robotic gastrectomy (RG) is expected to be advantageous for complicated operations. However, whether RG is superior to conventional laparoscopic gastrectomy (LG) for patients with visceral fat obesity remains unclear. The present study aimed to clarify the impact of RG on the short- and long-term outcomes of patients with high VFAs.

METHODS

This study included 1306 patients with clinical stage I/II gastric cancer who underwent minimally invasive gastrectomy between January 2012 and December 2020. The patients were subclassified according to VFA. The short- and long-term outcomes of RG were compared with those of LG in two VFA categories.

RESULTS

This study included 394 (high-VFA, 151; low-VFA, 243) and 882 patients (high-VFA, 366; low-VFA, 516) in the RG and LG groups, respectively. RG was associated with a significantly longer operative time than LG (high-VFA, P < 0.001; low-VFA, P < 0.001). The incidence rates of overall and intra-abdominal infectious complications in the high-VFA patients were lower in the RG group than in the LG group (P = 0.019 and P = 0.048, respectively) but not significantly different from those in the low-VFA patients. In the multivariate analysis, LG was identified as the only independent risk factor of overall (odds ratio [OR] 3.281; P = 0.012) and intra-abdominal infectious complications (OR 3.462; P = 0.021) in the high-VFA patients. The overall survival of high-VFA patients was significantly better in the RG group than in the LG group (P = 0.045).

CONCLUSIONS

For patients with visceral fat obesity, RG appears to be advantageous to LG in terms of reducing the risk of complications and better long-term survival.

Incidence and risk factors for postoperative pancreatic fistula in 2089 patients treated by radical gastrectomy: A prospective multicenter cohort study in China

OBJECTIVE

To determine the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) following radical gastrectomy and to identify independent risk factors of CR-POPF.

BACKGROUND

CR-POPF and its sequelae are potential complications following radical gastrectomy. The reported incidence of CR-POPF was quite different across various regions, and no consensus was reached.

METHODS

Between December 2017 to November 2018, patients who underwent radical gastrectomy from 22 centers across 13 regions in China were prospectively recruited. The primary endpoint was the occurrence of CR-POPF, defined by the International Study Group of Pancreatic Fistula (ISGPF) in 2016. Clinically relevant change and short-term outcomes were recorded to diagnose and grade the POPF. Multivariate regression analyses were performed to identify independent risk factors of clinically relevant postoperative pancreatic fistula (CR-POPF).

RESULTS

A total of 2089 cases were analyzed. The incidence of biochemical leakage (BL) and CR-POPF were 19.6% and 1.1% respectively. All CR-POPF patients recovered well after appropriate treatment and no Grade C POPF were recorded. Logistic regression analysis showed pTNM III (OR, 2.940; 95% CI 1.180-7.325; P = 0.021) and LigaSure usage (OR, 6.618; 95% CI 1.847-23.707; P = 0.004) were independent risk factors of CR-POPF. LigaSure usage (OR, 4.817; 95% CI 1.184-19.598; P = 0.028), the drain amylase content (D-AMY) on postoperative day 3 (POD3) ≥5 times the upper limit of normal amylase (OR, 3.476; 95% CI 1.240-9.744; P = 0.018) and open surgery (OR, 2.463; 95% CI 1.003-6.050; P = 0.049) were independent predictors for identifying CR-POPF from BL.

CONCLUSION

In rich-experienced gastric cancer centers, there is high prevalence of BL secondary to radical gastrectomy without clinical impact. Fewer patients suffered Grade B POPF, and Grade C POPF was less common. The patients with pTNM III or LigaSure usage were prone to suffer CR-POPF. Surgery procedure, LigaSure usage combined with D-AMY measurement on POD3 are promising for early identification of CR-POPF.

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.

Current status of robot-assisted minimally invasive esophagectomy: what is the real benefit?

Robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer has been performed increasingly frequently over the last few years. Robotic systems with articulated devices and tremor filtration allow surgeons to perform such procedures more meticulously than by hand. The feasibility of RAMIE has been demonstrated in several retrospective comparative studies, which showed similar short-term outcomes to conventional minimally invasive esophagectomy (cMIE). Considering the number of harvested lymph nodes, RAMIE may be superior to cMIE in terms of left upper mediastinal lymph node dissection. However, whether or not the addition of a robotic system to cMIE can help improve perioperative and oncological outcomes remains unclear. Given the lack of established evidence from randomized controlled trials, we must await the results of ongoing studies to reach any meaningful conclusions. Further advancements in robotic platforms, as well as the reduction in medical expenses, will be essential to demonstrate the real benefit of RAMIE.

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.

Reduction in postoperative complications by robotic surgery: a case-control study of robotic versus conventional laparoscopic surgery for gastric cancer

Background

Robotic gastrectomy (RG) is being increasingly performed globally; it is considered an evolved type of conventional laparoscopic surgery with excellent dexterity and precision, but higher costs and longer operation time. Thus, there is a need to identify the benefits from RG and its specific candidates.

Methods

This retrospective study analyzed data from a prospectively collected clinical database at our center. Data of patients with primary gastric cancer undergoing either robotic or laparoscopic radical gastrectomy from June 2014 to June 2020 were reviewed. Surgical outcomes were compared between the two groups, and multivariable analyses were performed to elucidate the relevant factors for postoperative complications in several subgroups.

Results

A total of 1172 patients were divided into those who underwent RG (n = 152) and those who underwent laparoscopic gastrectomy (LG) (n = 1020). Baseline characteristics were similar in the two groups, except the RG group included more patients undergoing total/proximal gastrectomy (TG/PG) and patients at clinical stage III. Compared with the LG group, the RG group had lower incidences of postoperative complications ≥ Clavien-Dindo grade III (2/152 (1.3%) versus 72/1020 (7.1%); P = 0.004), and intraabdominal complications ≥ grade II (6/152 (3.9%) versus 119/1020 (11.7%); P = 0.004). Multivariable analysis revealed that RG was a significant relevant factor for reducing overall postoperative complications (≥ grade III) (odds ratio (OR) 0.16, P = 0.013), and intraabdominal complications (≥ grade II) (OR 0.29, P = 0.002). Subgroup analyses demonstrated that this tendency was enhanced in patients undergoing TG/PG (OR 0.29, P = 0.021) or at clinical stage II/III (OR 0.10, P = 0.027).

Conclusions

RG reduces the incidence of postoperative complications compared with conventional LG and this tendency may be enhanced in technically complicated procedures with demanding anastomosis or D2 lymphadenectomy. Patients requiring such procedures would most benefit from RG.

Robotic esophagectomy with total mediastinal lymphadenectomy using four robotic arms alone in esophageal and esophagogastric cancer (RETML-4): a prospective feasibility study

BACKGROUND

Robotic-assisted esophagectomy is still in the implementation phase. Robotic surgical systems refine visualization via robotically-enhanced surgical anatomy (RESA), and the stable articulated robotic arms provide precise movements. This prospective feasibility study was conducted to evaluate robotic esophagectomy with total mediastinal lymphadenectomy using four robotic arms exclusively (RETML-4).

METHODS

The inclusion criterion was clinical stage I-IIIB esophageal cancer with stable general condition. Patients were positioned hemi-prone with single-lung ventilation, and the operation table was tilted until the patient was prone. The first, second, third, and fourth robotic ports were inserted into the ninth intercostal space (ICS) on the angulus inferior scapulae line, seventh ICS on the posterior axillary line, and the fifth and third ICS on the mid-axillary line, respectively. RETML-4 was performed by precise sharp dissection in wide stable operation fields, with countertraction created by a tip-up fenestrated grasper with gauze. Esophagectomy was performed separately for the middle to lower, and upper esophagus. After mobilizing the middle to lower esophagus and performing lymph node dissection, the upper esophagus was mobilized, with bilateral lymph node dissection along the recurrent laryngeal nerves. The assistant surgeon was involved only during removing gauze and collecting harvested lymph nodes in the thorax.

RESULTS

RETML-4 was performed in all ten patients enrolled in 2018. The median postoperative hospital stay was 15 days, and the complication rate was 60%. Nine cases achieved R0 resection. Recurrence occurred in two cases.

CONCLUSIONS

RETML-4 is feasible, and may facilitate minimally invasive esophagectomy by providing precise instrument movements and RESA.

Gastric equivalent of the 'Holy Plane' to standardize the surgical concept of stomach cancer to mesogastric excision: updating Jamieson and Dobson's historic schema

BACKGROUND

Surgery for curable gastric cancer has historically involved dissection of lymph nodes, depending on the risk of metastasis. By establishing the concept of mesogastric excision (MGE), we aim to make this approach compatible with that for colorectal cancer, where the standard is excision of the mesentery.

METHODS

Current advances in molecular embryology, visceral anatomy, and surgical techniques were integrated to update Jamieson and Dobson's schema, a historical reference for the mesogastrium.

RESULTS

The mesogastrium develops with a three-dimensional movement, involving multiple fusions with surrounding structures (retroperitoneum or other mesenteries) and imbedding parenchymal organs (pancreas, liver, and spleen) that grow within the mesentery. Meanwhile, the fusion fascia and the investing fascia interface with adjacent structures of different embryological origin, which we consider to be equivalent to the 'Holy Plane' in rectal surgery emphasized by Heald in the concept of total mesorectal excision. Dissecting these fasciae allows for oncologic MGE, consisting of removing lymph node-containing mesenteric adipose tissue with an intact fascial package. MGE is theoretically compatible with its colorectal counterpart, although complete removal of the mesogastrium is not possible due to the need to spare imbedded vital organs. The celiac axis is treated as the central artery of the mesogastrium, but is peripherally ligated by tributaries flowing into the stomach to feed the spared organs.

CONCLUSION

The obscure contour of the mesogastrium can be clarified by thinking of it as the gastric equivalent of the 'Holy Plane'. MGE could be a standard concept for surgical treatment of stomach cancer.

Laparoscopic Completion Total Gastrectomy as a Standardized Procedure for Gastric Stump Cancer: A Case Control Study

Objective

Complete gastrectomy for gastric stump cancer (GSC) can be challenging due to severe adhesions; therefore, advanced techniques are required when being performed by laparoscopic surgery. This study aimed to evaluate the clinical outcomes of laparoscopic completion total gastrectomy (LCTG) for the treatment of GSC.

Methods

Patient records from January 2010 to October 2018 were retrospectively evaluated. The patients were classified into 2 groups depending on whether they underwent open or laparoscopic gastrectomy. We compared patient characteristics; operative, clinical, and pathological data between the groups.

Results

Twenty open and 17 LCTGs were performed. Laparoscopic gastrectomy resulted in a significantly longer operation time (230 versus 182.5 min; P = 0.026), lower blood loss (14 versus 105 mL; P &lt; 0.001), and shorter period to the first flatus passage (2 versus 3 days; P &lt; 0.001) than open gastrectomy. No significant differences in the number of retrieved lymph nodes, duration of hospital stay, complication rate, and postoperative analgesic usage between the 2 groups were observed. No patients required conversion to open surgery in the laparoscopic-treatment group. Pathologic findings revealed that the laparoscopic group had a smaller tumor size (not pathologic T category) and fewer metastatic lymph nodes than the open group, leading to an earlier distribution of the pathologic stage in the laparoscopic group.

Conclusions

LCTG for the treatment of GSC was safely conducted with fewer complications and mortalities than previously reported results. Advanced technologies and sophistication of laparoscopic skills may further yield minimal invasiveness with better short-term outcome.

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.

Should robotic gastrectomy become a standard surgical treatment option for gastric cancer?

Robotic gastrectomy (RG) using the da Vinci Surgical System for gastric cancer was approved for national medical insurance coverage in Japan in April, 2018, and has been used increasingly since. We reviewed the current evidence on RG, open gastrectomy (OG), and conventional laparoscopic gastrectomy (LG) to identify differences in surgical outcomes between Japan and other countries. Briefly, three independent reviewers systematically reviewed the data collected from a comprehensive literature search by an independent organization and focused on the following nine endpoints: mortality, morbidity, operative time, estimated volume of blood loss, length of postoperative hospital stay, long-term oncologic outcome, quality of life, learning curve, and cost. Overall, the mortality rate of the three approaches did not differ, but RG and LG had less intraoperative blood loss and resulted in a shorter postoperative hospital stay than OG. RG had longer operative times and incurred higher costs than LG and OG. However, in Japan, RG may be more effective than LG and OG for decreasing morbidity. Further studies are needed to establish the specific indications for RG, optimal robotic setup, and dissection methods to best utilize the surgical robot.

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.

Morbidity and short-term surgical outcomes of robotic versus laparoscopic distal gastrectomy for gastric cancer: a large cohort study

BACKGROUND

Robotic distal gastrectomy (RDG) has been increasingly used for the treatment of gastric cancer in recent year. However, whether RDG could reduce the morbidity when compared to laparoscopic distal gastrectomy (LDG) remains controversial. This study aimed to compare the morbidity and short-term surgical outcomes of RDG and LDG for gastric cancer and identify the related risk factors.

METHODS

Between March 2010 and August 2019, consecutive patients undergoing RDG or LDG (519 and 957 patients, respectively) at our institution were included in this study. Postoperative complications were stratified according to the Clavien-Dindo (C-D) classification. We performed one-to-one propensity score matching (PSM) analysis, and evaluated postoperative morbidity and short-term surgical outcomes in PSM 1032 patients undergoing RDG or LDG.

RESULTS

After PSM, the two groups were well-balanced. The mean blood loss of the RDG group was about 27 mL less than that of the LDG group (112.1 vs 139.0 mL, P < 0.001). The RDG group had more retrieved lymph nodes than that in the LDG group (32.7 v 30.2, P < 0.001). The RDG group showed a similar overall (9.9% vs 10.7%, P = 0.682), severe (2.7% vs 3.7%, P = 0.376), local (5.6% vs 5.2%, P = 0.783), and systemic complication rates (5.4% vs 6.0%, P = 0.688). There were no significant differences in mortality between the two groups (RDG 0% vs LDG 0.2%, P = 1.000). Subgroup analyses showed no significant differences in most stratified parameters. Age > 65 years and ASA III were identified as two major risk factors for complications.

CONCLUSION

RDG could be a safe and feasible in treating gastric cancer compared to LDG. However, we did not observe significant reduction in postoperative complications of RDG compared with LDG, although the use of robotic system is assumed to provide a technically superior operative environment.

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.

Clinical advantages of robotic gastrectomy for clinical stage I/II gastric cancer: a multi-institutional prospective single-arm study

BACKGROUND

Robotic gastrectomy (RG) for gastric cancer (GC) has been increasingly performed for a decade; however, evidence for its use as a standard treatment has not yet been established. The present study aimed to determine the safety, feasibility, and effectiveness of RG for GC.

METHODS

This multi-institutional, single-arm prospective study, which included 330 patients from 15 institutions, was designed to compare morbidity rate of RG with that of a historical control (conventional laparoscopic gastrectomy, LG). This trial was approved for Advanced Medical Technology ("Senshiniryo") B. The included patients were operable patients with cStage I/II GC. The primary endpoint was morbidity (Clavien-Dindo Grade ≥ IIIa). The specific hypothesis was that RG could reduce the morbidity rate to less than half of that with LG (6.4%). A sample size of 330 was considered sufficient (one-sided alpha 0.05, power 80%).

RESULTS

Among the 330 study patients, the protocol treatment was suspended in 4 patients. Thus, 326 patients fully enrolled and completed the study. The median patient age and BMI were 66 years and 22.4 kg/m2, respectively. Distal gastrectomy was performed in 253 (77.6%) patients. The median operative time and estimated blood loss were 313 min and 20 mL, respectively. No 30-day mortality was seen, and morbidity showed a significant reduction to 2.45% with RG (p = 0.0018).

CONCLUSIONS

RG for cStage I/II GC is safe and feasible. It may be effective in reducing morbidity with LG.

Robotic-assisted gastrectomy for gastric cancer: a European perspective

Gastrectomy is the mainstay treatment for gastric cancer. To reduce the associated patient burden, minimally invasive gastrectomy was introduced in almost 30 years ago. The increase in the availability of surgical robotic systems led to the first robotic-assisted gastrectomy to be performed in 2002 in Japan. Robotic gastrectomy however, particularly in Europe, has not yet gained significant traction. Most reports to date are from Asia, predominantly containing observational studies. These cohorts are commonly different in the tumour stage, location (particularly with regards to gastroesophageal junctional tumours) and patient BMI compared to those encountered in Europe. To date, no randomised clinical trials have been performed comparing robotic gastrectomy to either laparoscopic or open equivalent. Cohort studies show that robotic gastrectomy is equal oncological outcomes in terms of survival and lymph node yield. Operative times in the robotic group are consistently longer compared to laparoscopic or open gastrectomy, although evidence is emerging that resectional surgical time is equal. The only reproducibly significant difference in favour of robot-assisted gastrectomy is a reduction in intra-operative blood loss and some studies show a reduction in the risk of pancreatic fistula formation.

Gastric Cancer Etiology and Management in Asia and the West

Regional variation in treatment paradigms for gastric adenocarcinoma has attracted a great deal of interest. Between Asia and the West, major differences have been identified in tumor biology, implementation of screening programs, extent of surgical lymphadenectomy, and routine use of neoadjuvant versus adjuvant treatment strategies. Minimally invasive techniques, including both laparoscopic and robotic platforms, have been studied in both regions, with attention to safety, feasibility, and long-term oncologic outcomes. The purpose of this review is to discuss advances in the understanding of the etiology and underlying biology of gastric cancer, as well as the current state of management, focusing on the differences between Asia and the West.

Pancreatic Complications After Conventional Laparoscopic Radical Gastrectomy Versus Robotic Radical Gastrectomy: Systematic Review and Meta-Analysis

BACKGROUND

Recent reports have suggested that the use of the robot might reduce the rate of pancreatic complications following minimally invasive radical gastrectomy.

METHODS

By meta-analyzing the available literature, we aimed to elucidate possible differences between conventional laparoscopic and robotic radical gastrectomy on pancreatic morbidity.

RESULTS

More than 2000 patients from eight studies were eventually included in the analysis. The overall incidence of postoperative pancreatic complications was 2.2%, being 1.7% and 2.5% following robotic and laparoscopic gastrectomy (LG), respectively. In particular, pancreatic fistula occurred in 2.7% of patients receiving robotic gastrectomy (RG) and 3.8% of patients receiving laparoscopy.

CONCLUSIONS

The use of the robot showed a trend toward better outcomes compared with laparoscopy, despite the presence of more advanced disease and higher body mass index. The meta-analysis resulted in an odd ratio of 0.8 favoring RG over LG on pancreatic morbidity, although without statistical significance.

Robotic oesophago-gastric cancer surgery

A postoperative complications rate of nearly 50% has compelled oesophago-gastric practice to adopt minimally invasive techniques such as robotic surgery

Impact of an Ultrasonically Activated Device in Robot-Assisted Distal Gastrectomy

Objective

Robot-assisted gastrectomy is increasingly used for the treatment of gastric cancer, although it remains a time-consuming procedure. An ultrasonically activated device might be useful to shorten operation times. This study therefore assessed the effect of ultrasonically activated device use on procedural times and on other early surgical outcomes.

Methods

Consecutive patients (N = 42) who underwent robot-assisted distal gastrectomy for gastric cancer were included. Clinicopathological characteristics and early surgical outcomes were compared between robotic-assisted gastrectomy procedures using an ultrasonically activated device (U group, n = 21) and those without it (NU group, n = 21).

Results

There were no significant differences in patient characteristics between the groups; however, the median operation time was significantly less in the U group than in the NU group (291 vs 351 minutes, P = 0.006). In detail, the median duration of console time until dividing the duodenum was less in the U group (70 vs 102 minutes, P < 0.001). Estimated blood loss, incidence of postoperative morbidity, and duration of postoperative hospital stay were not different between the groups.

Conclusions

An ultrasonically activated device reduced the operation time of robot-assisted gastrectomy without increasing blood loss and morbidity.

Universalization of the operative strategy by systematic mesogastric excision for stomach cancer with that for total mesorectal excision and complete mesocolic excision colorectal counterparts

Gastrointestinal cancer surgery aims at en bloc removal of the primary tumor with its lymphatic drainage by excising organ-specific mesentery as an "intact package". This concept was advocated in colorectal cancer surgery as total mesorectal excision (TME) or complete mesocolic excision (CME) procedures, but is not directly applicable to stomach cancer as a result of the morphological complexities of the gastric mesentery. In this review, we discuss the unique anatomical features of the mesogastrium by introducing its embryology, disclose its similarity to the mesosigmoid, and then propose a theoretical concept to mesentery-based D2 gastrectomy, namely systematic mesogastric excision, which can universalize the operative strategy of stomach cancer with that of TME and CME colorectal counterparts.

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

Background

Advanced minimally invasive techniques including robotic surgery are being employed with increasing frequency around the world, primarily in order to improve the surgical outcomes of laparoscopic gastrectomy (LG). We conducted a systematic review and meta-analysis to evaluate the feasibility, safety and efficacy of robotic gastrectomy (RG).

Methods

Studies, which compared surgical outcomes between LG and RG, were retrieved from medical databases before May 2017. Outcomes of interest were estimated as weighted mean difference (WMD) or risk ratio (RR) using the random-effects model. The software Review Manage version 5.1 was used for all calculations.

Results

Nineteen comparative studies with 5953 patients were included in this analysis. Compared with LG, RG was associated with longer operation time (WMD = −49.05 min; 95% CI: -58.18 ~ −39.91, P < 0.01), less intraoperative blood loss (WMD = 24.38 ml; 95% CI: 12.32 ~ 36.43, P < 0.01), earlier time to oral intake (WMD = 0.23 days; 95% CI: 0.13 ~ 0.34, P < 0.01), and a higher expense (WMD = −3944.8 USD; 95% CI: -4943.5 ~ −2946.2, P < 0.01). There was no significant difference between RG and LG regarding time to flatus, hospitalization, morbidity, mortality, harvested lymph nodes, and cancer recurrence.

Conclusions

RG can be performed as safely as LG. However, it will take more effort to decrease operation time and expense.

Robotic gastrectomy for gastric cancer: Current evidence

The robotic system has gained wide acceptance in specialties such as urological and gynecological surgery. It has also been applied in the field of upper gastrointestinal surgery. Since the first implementation of the robotic system for the treatment of gastric adenocarcinoma, the procedure has been found to be safe and feasible. Although robotic gastrectomy does not meet our expectations and yield better results than laparoscopic gastrectomy, this procedure seems to provide several advantages over laparoscopy such as reduced blood loss, shorter learning curves and increased number of retrieved lymph nodes. However, as many case series, including a recent multicenter study, have revealed, higher cost and longer operation time are the major limitations of robotic gastrectomy. Furthermore, there are no results from well-designed randomized clinical trials comparing the two procedures. New procedures in much more technically demanding cases will test the genuine benefits of robotic gastrectomy.

Robotic gastrectomy for gastric cancer

The number of robotic gastrectomy (RG) performed per year has been increasing, particularly in East Asia where the incidence of gastric cancer is high and approximately half of the cases are diagnosed as early gastric cancer. With articulated devices of RG, surgeons are able to perform every procedure more meticulously, which can result in less bleeding and damage to organs. There are many single arm and comparative studies, and these study showed similar trends, which included relatively less estimated blood loss and longer operation time following RG than laparoscopic gastrectomy (LG), equivalent number of harvested lymph nodes and similar length of postoperative hospital stay between RG and LG. Considering the results of these retrospective comparative studies, RG seems to be as feasible as LG in terms of early surgical outcomes. However, medical expense of RG is approximately twice as much as that of LG. Lack of solid evidence in terms of long-term outcomes is another problem. Considering the higher medical expenses associated with RG, its superiority in terms of long-term survival outcomes needs to be confirmed in the future for it to be accepted more widely.

Status and Prospects of Robotic Gastrectomy for Gastric Cancer: Our Experience and a Review of the Literature

Since the first report of robotic gastrectomy, experienced laparoscopic surgeons have used surgical robots to treat gastric cancer and resolve problems associated with laparoscopic gastrectomy. However, compared with laparoscopic gastrectomy, the superiority of robotic procedures has not been clearly proven. There are several advantages to using robotic surgery for gastric cancer, such as reduced estimated blood loss during the operation, a shorter learning curve, and a larger number of examined lymph nodes than conventional laparoscopic gastrectomy. The increased operation time observed with a robotic system is decreasing because surgeons have accumulated experience using this procedure. While there is limited evidence, long-term oncologic outcomes appear to be similar between robotic and laparoscopic gastrectomy. Robotic procedures have a significantly greater financial cost than laparoscopic gastrectomy, which is a major drawback. Recent clinical studies tried to demonstrate that the benefits of robotic surgery outweighed the cost, but the overall results were disappointing. Ongoing studies are investigating the benefits of robotic gastrectomy in more complicated and challenging cases. Well-designed randomized control trials with large sample sizes are needed to investigate the benefits of robotic gastrectomy compared with laparoscopic surgery.

Minimally Invasive Surgical Approaches to Gastric Resection

Minimally invasive gastric resections carry several advantages, including less intraoperative blood loss, faster recovery time, reduced pain, and decreased hospital length of stay and quicker return to work. Numerous trials have proved that laparoscopic and robotic-assisted gastrectomy provides equivalent surgical and oncologic outcomes to open approaches. As with any minimally invasive approach, advanced minimally invasive training and good judgment by a surgeon are paramount in selecting patients in whom a minimally invasive approach is feasible. With increasing research in patient populations with more advanced disease, the indications are likely to continue to expand.

Comparison of the long-term outcomes of robotic radical gastrectomy for gastric cancer and conventional laparoscopic approach: a single institutional retrospective cohort study

BACKGROUND

Robotic gastrectomy (RG) for gastric cancer (GC) has been increasingly performed over the last decade. The technical feasibility and safety of RG for GC, predominantly early GC, have previously been reported; however, few studies have evaluated the oncological outcomes. This study aimed to determine the long-term outcomes of RG for GC compared with those of conventional laparoscopic gastrectomy (LG).

METHODS

Of the 521 consecutive patients with GC who underwent radical gastrectomy at our institution between 2009 and 2012, 84 consecutive patients who underwent RG and 437 patients who received LG were enrolled in this study. Long-term outcomes including the 3-year overall survival (3yOS) and 3-year recurrence-free survival rates (3yRFS) were examined retrospectively.

RESULTS

In the RG group, the 3yOS rates stratified by pathological stage according to the Japanese classification of gastric carcinoma (IA, IB, II, and III) were 94.7, 90.9, 89.5, and 62.5 %, respectively. No differences in 3yOS (RG, 86.9 % vs. LG, 88.8 %; p = 0.636) or 3yRFS (RG, 86.9 % vs. LG, 86.3 %; p = 0.905) were observed between the groups. 3yOS was strongly associated with cancer recurrence within 3 years (p < 0.001), while 3yRFS was associated with tumor size ≥ 30 mm (p < 0.001), clinical stage ≥ IB (p < 0.001), estimated blood loss ≥ 50 mL (p = 0.033), and postoperative pancreatic fistula CD grade ≥ III) (p = 0.035).

CONCLUSIONS

RG for GC was feasible and safe from the oncological point of view in a cohort including a considerable number of patients with advanced GC.