Robotic versus open oncological gastric surgery in the elderly: a propensity score-matched analysis

Clinical benefits including the postoperative inflammatory status of robot-assisted distal gastrectomy for gastric cancer compared with laparoscopic distal gastrectomy in patients with obesity

This study aimed to clarify the clinical benefits of robot-assisted distal gastrectomy (RDG) versus laparoscopic distal gastrectomy (LDG) in patients with obesity.The analysis included 89 and 87 patients in LDG and RDG groups, respectively. The associations between body mass index (BMI) and surgical outcomes including postoperative inflammation were compared between LDG and RDG.Incidences of postoperative complications did not show a significant difference between LDG and RDG. The operating time and blood loss increased with BMI in the LDG group, whereas no such correlation was observed in the RDG group. While BMI and C-reactive protein (CRP) levels on postoperative day (POD) 3 showed a significant correlation in LDG (R = 0.393, p < 0.001), RDG did not show a correlation. In patients with BMI ≥ 25 (kg/m2), CRP on POD 3 was significantly lower in RDG than in LDG. Multivariate analysis for CRP on POD 3 in patients with BMI ≥ 25 identified RDG and operating time ≥ 360 min as independent associated factors (B = - 6.887; p = 0.003 and B = 6.068; p = 0.011).RDG was indicated to reduce blood loss and suppress the postoperative CRP elevation compared with LDG, particularly in patients with high BMI.

A systematic review on the effectiveness of robot-assisted minimally invasive gastrectomy

BACKGROUND

Robot-assisted minimally invasive gastrectomy (RAMIG) is increasingly used as a surgical approach for gastric cancer. This study assessed the effectiveness of RAMIG and studied which stages of the IDEAL-framework (1 = Idea, 2A = Development, 2B = Exploration, 3 = Assessment, 4 = Long-term follow-up) were followed.

METHODS

The Cochrane Library, Embase, Pubmed, and Web of Science were searched for studies on RAMIG up to January 2023. Data collection included the IDEAL-stage, demographics, number of participants, and study design. For randomized controlled trials (RCTs) and long-term studies, data on intra-, postoperative, and oncologic outcomes, survival, and costs of RAMIG were collected and summarized.

RESULTS

Of the 114 included studies, none reported the IDEAL-stage. After full-text reading, 18 (16%) studies were considered IDEAL-2A, 75 (66%) IDEAL-2B, 4 (4%) IDEAL-3, and 17 (15%) IDEAL-4. The IDEAL-stages were followed sequentially (2A-4), with IDEAL-2A studies still ongoing. IDEAL-3 RCTs showed lower overall complications (8.5-9.2% RAMIG versus 17.6-19.3% laparoscopic total/subtotal gastrectomy), equal 30-day mortality (0%), and equal length of hospital stay for RAMIG (mean 5.7-8.5 days RAMIG versus 6.4-8.2 days open/laparoscopic total/subtotal gastrectomy). Lymph node yield was similar across techniques, but RAMIG incurred significantly higher costs than laparoscopic total/subtotal gastrectomy ($13,423-15,262 versus $10,165-10,945). IDEAL-4 studies showed similar or improved overall/disease-free survival for RAMIG.

CONCLUSION

During worldwide RAMIG implementation, the IDEAL-framework was followed in sequential order. IDEAL-3 and 4 long-term studies showed that RAMIG is similar or even better to conventional surgery in terms of hospital stay, lymph node yield, and overall/disease-free survival. In addition, RAMIG showed reduced postoperative complication rates, despite higher costs.

Comparison of Short-Term Outcomes after Robotic Surgery for Gastric Cancer in Elderly and Younger Patients: A Retrospective Cohort Study

Robot-assisted surgery has recently been introduced to overcome some drawbacks and technical limitations in performing laparoscopic gastrectomy. The aim of the present study was to evaluate the feasibility and safety of robotic gastrectomy in elderly patients. The study enrolled 143 patients who underwent robotic gastrectomy in a single high-volume centre. All patients were divided into two groups based on age: elderly group ≥ 75 years old (EG; n = 64) and non-elderly group < 75 years old (NEG; n = 79). Comorbidities were significantly more frequent in the EG (95.3%) than in the NEG (81%) (p = 0.011). Similarly, the percentage of ASA 3 patients was significantly higher in the EG than in the NEG (43.8% vs. 24.0%, respectively; p = 0.048). Nevertheless, the incidence of Clavien-Dindo grade III and IV complications did not differ significantly between the two groups (10.9% in the EG and 6.3% in the NEG; p = 0.852). Moreover, operative time, re-operation rate, mean number of harvested lymph nodes, 30-day mortality, and median hospital stay were similar within the two groups. Our study suggests that robotic gastrectomy can be performed safely for elderly patients. In particular, chronological age does not seem to affect either the clinical or oncological short-term outcomes after robotic gastrectomy.

Optimizing Acetabular Positioning: A Comprehensive Review of Contemporary Strategies in Total Hip Arthroplasty

Total hip arthroplasty (THA) is a widely practiced surgical intervention to alleviate pain and reinstate functionality in individuals afflicted with hip joint pathology. The positioning of the acetabulum assumes paramount significance in determining the efficacy of THA, exerting profound influences on biomechanical dynamics, stability, and the durability of outcomes over time. This comprehensive review meticulously evaluates contemporary methodologies for optimizing acetabular positioning in THA, encompassing advanced technologies such as computer-assisted navigation systems, patient-specific instrumentation, robotic-assisted surgical approaches, image-based planning techniques, and intraoperative fluoroscopy. Crucially, key discoveries underscore the pivotal role of precise acetabular alignment in mitigating complications such as dislocation, component wear, and impingement. Moreover, the implications for clinical practice accentuate the imperative of continuous education and training to ensure effective deployment of sophisticated methodologies. Recommendations for furthering research and enhancing practice development underscore the necessity of scrutinizing long-term prognoses, assessing cost-effectiveness, and embracing technological innovations perpetually refining THA outcomes. Collaborative endeavors among researchers, practitioners, and industry stakeholders emerge as indispensable drivers of advancement in this domain, fostering an environment conducive to elevating the standard of care for individuals undergoing THA.

Prince and princesses: The current status of robotic surgery in surgical oncology

Robotic surgery has experienced a dramatic increase in utilization across general surgery over the last two decades, including in surgical oncology. Although urologists and gynecologists were the first to show that this technology could be utilized in cancer surgery, the robot is now a powerful tool in the treatment of gastrointestinal, hepato-pancreatico-biliary, colorectal, endocrine, and soft tissue malignancies. While long-term outcomes are still pending, short-term outcomes have showed promise for this technologic advancement of cancer surgery.

Surgical Frontiers: A Comparative Review of Robotics Versus Laparoscopy in Gynecological Interventions

This review comprehensively examines the current state and future directions of gynecological surgery, focusing on the comparative analysis of laparoscopy and robotic surgery. The overview highlights the evolution of these surgical techniques, emphasizing their impact on patient outcomes, procedural efficiency, and safety profiles. The analysis encompasses critical factors such as cost-effectiveness, learning curves, and implications for postoperative recovery. The future of gynecological surgery is envisioned through emerging technologies, including augmented reality, single-incision laparoscopy, and artificial intelligence. The coexistence of laparoscopy and robotics is explored, acknowledging their respective strengths and roles in shaping women's healthcare. In conclusion, the dynamic nature of the field is underscored, emphasizing the need for a patient-centered and adaptable approach. Collaboration between healthcare professionals, engineers, and researchers is pivotal in unlocking these innovations' full potential, ensuring continued advancements in gynecological surgery for improved outcomes and enhanced patient care.

Open vs robotic gastrectomy with D2 lymphadenectomy: a propensity score-matched analysis on 1469 patients from the IMIGASTRIC prospective database

BACKGROUND

Comparative data on D2-robotic gastrectomy (RG) vs D2-open gastrectomy (OG) are lacking in the Literature. Aim of this paper is to compare RG to OG with a focus on D2-lymphadenectomy.

STUDY DESIGN

Data of patients undergoing D2-OG or RG for gastric cancer were retrieved from the international IMIGASTRIC prospective database and compared.

RESULTS

A total of 1469 patients were selected for inclusion in the study. After 1:1 propensity score matching, a total of 580 patients were matched and included in the final analysis, 290 in each group, RG vs OG. RG had longer operation time (210 vs 330 min, p < 0.0001), reduced intraoperative blood loss (155 vs 119.7 ml, p < 0.0001), time to liquid diet (4.4 vs 3 days, p < 0.0001) and to peristalsis (2.4 vs 2 days, p < 0.0001), and length of postoperative stay (11 vs 8 days, p < 0.0001). Morbidity rate was higher in OG (24.1% vs 16.2%, p = 0.017).

CONCLUSION

RG significantly expedites recovery and reduces the risk of complications compared to OG. However, long-term survival is similar.

Robotic versus open approach in total gastrectomy for gastric cancer: a comparative single-center study of perioperative outcomes

The robotic approach to gastric cancer has been gaining interest in recent years; however, its benefit over the open procedure in total gastrectomy with D2 lymphadenectomy is still controversial. The aims of the study were to compare postoperative morbidity and mortality, hospital stay, and anatomopathological findings between the robotic and open approaches to oncologic total gastrectomy. We analyzed a prospectively collected database, which included patients who underwent total gastrectomy with D2 lymphadenectomy in our center using a robotic or an open approach between 2014 and 2021. Comparative analysis of clinicopathological, intraoperative, postoperative and anatomopathological variables between the robot-assisted group and the open group was performed. Thirty patients underwent total gastrectomy with D2 lymphadenectomy by a robotic approach and 48 patients by an open procedure. Both groups were comparable. The robot-assisted group presented a lower rate of Clavien-Dindo complications ≥ stage II (20 vs. 48%, p = 0.048), a shorter hospital stay (7 days vs. 9 days, p = 0.003) and had a higher total number of lymph nodes resected (22 nodes vs. 15 nodes, p = 0.001) compared to the open approach. Operative time was longer in the robotic group (325 min vs. 195 min, p < 0.001) compared to the open group. The robotic approach is associated with a longer surgical time, a lower rate of Clavien-Dindo complications ≥ stage II and a shorter hospital stay, and more lymph nodes were resected compared to the open approach.

Robotic-assisted Gynecological Surgery in Older Patients - a Comparative Cohort Study of Perioperative Outcomes

Study design Because of current demographic developments, a hypothesis was proposed whereby older female patients aged > 65 years can be safely operated using minimally invasive, robotic-assisted surgery, despite having more preoperative comorbidities. A comparative cohort study was designed to compare the age group ≥ 65 years (older age group, OAG) with the age group < 65 years (younger age group, YAG) after robotic-assisted gynecological surgery (RAS) in two German centers. Patients and methods Consecutive RAS procedures performed between 2016 and 2021 at the Women's University Hospital of Jena and the Robotic Center Eisenach to treat benign or oncological indications were included in the study. The age groups were compared according to their preoperative comorbidities (ASA, Charlson comorbidity index [CCI], cumulative illness rating scale - geriatric version [CIRS-G]) and perioperative parameters such as Clavien-Dindo (CD) classification of surgical complications. Analysis was performed using Welch's t -test, chi ² test, and Fisher's exact test. Results A total of 242 datasets were identified, of which 63 (73 ± 5 years) were OAG and 179 were YAG (48 ± 10 years). Patient characteristics and the percentage of benign or oncological indications did not differ between the two age groups. Comorbidity scores and the percentage of obese patients were higher in the OAG group: CCI (2.7 ± 2.0 vs. 1.5 ± 1.3; p < 0.001), CIRS-G (9.7 ± 3.9 vs. 5.4 ± 2.9; p < 0.001), ASA class II/III (91.8% vs. 74.1%; p = 0.004), obesity (54.1% vs. 38.2%; p = 0.030). There was no difference between age groups, even grouped for benign or oncological indications, with regard to perioperative parameters such as duration of surgery (p = 0.088; p = 0.368), length of hospital stay (p = 0.786; p = 0.814), decrease in Hb levels (p = 0.811; p = 0.058), conversion rate (p = 1.000; p = 1.000) and CD complications (p = 0.433; p = 0.745). Conclusion Although preoperative comorbidity was higher in the group of older female patients, no differences were found between age groups with regard to perioperative outcomes following robotic-assisted gynecological surgery. Patient age is not a contraindication for robotic gynecological surgery.

Gastrectomy for cancer beyond life expectancy. A comprehensive analysis of oncological gastric surgery in Germany between 2008 and 2018

INTRODUCTION

Major gastric surgery for distal esophageal and gastric cancer has a strong impact on the quality of life, morbidity, and mortality. Especially in elderly patients reaching their life expectancy, the responsible use and extent of gastrectomy are imperative to achieve a balance between harm and benefit. In the present study, the reimbursement database (German Diagnosis Related Groups (G-DRG) database) of the Statistical Office of the Federal Republic of Germany was queried to evaluate the morbidity and mortality of patients aged above or below 75 years following gastrectomy.

MATERIAL AND METHODS

All patients in Germany undergoing subtotal gastrectomy (ST), total gastrectomy (T), or gastrectomy combined with esophagectomy (TE) for gastric or distal esophageal cancer (International Statistical Classification of Diseases and Related Health Problems Version 10 (ICD-10) C15.2, C15.5, and C16.0-C16.9) between 2008 and 2018 were included. Intraoperative and postoperative complications as well as comorbidities, in-hospital mortality, and the extent of surgery were assessed by evaluating ICD-10 and operation and procedure key (Operationen- und Prozedurenschlüssel) codes.

RESULTS

A total of 67,389 patients underwent oncologic gastric resection in Germany between 2008 and 2018. In total, 21,794 patients received ST, 41,825 received T, and 3,466 received TE, respectively. In 304 cases, the combinations of these, in fact, mutually exclusive procedures were encoded. The proportion of patients aged 75 years or older was 51.4% (n = 11,207) for ST, 32.6% (n = 13,617) for T, and 28.1% (n = 973) for TE. The in-hospital mortality of elderly patients was significantly increased in all three groups. (p < 0.0001) General complications such as respiratory failure (p = 0.0054), acute renal failure (p < 0.0001), acute myocardial failure (p < 0.0001), and the need for resuscitation (ST/T: p < 0.0001/TE: p = 0.0218) were significantly increased after any kind of gastrectomy. Roux-en Y was the most commonly applied reconstruction technique in both young and elderly patients. Regarding lymphadenectomy, systematic D2 dissection was performed less frequently in older patients than in the younger collective in the case of ST and T as well as D3 dissection. Peritonectomy and hyperthermic intraperitoneal chemotherapy were uncommon in elderly patients alongside ST and T compared to younger patients (p < 0.0001).

CONCLUSION

The clinical outcome of major oncological gastric surgery is highly dependent on a patient's age. The elderly show a tremendously increased likelihood of in-hospital mortality and morbidity.

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

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