Postoperative pancreatic fistula after robot distal gastrectomy

Clinical Impact of Polyglycolic Acid Mesh to Reduce Pancreas-Related Complications After Minimally Invasive Surgery for Gastric Cancer: A Propensity Score Matching Analysis

PURPOSE

Prevention of pancreas-related complications after gastric cancer surgery is critical. Polyglycolic acid (PGA) mesh reduces postoperative pancreatic fistula formation following pancreatic resection. However, the clinical efficacy of PGA mesh in gastric cancer surgery has not been adequately investigated.

MATERIALS AND METHODS

This retrospective study compared the short-term outcomes between two groups: patients who underwent minimally invasive R0 gastrectomy for gastric cancer with the use of a PGA mesh (PGA group) and those without the use of a PGA mesh (non-PGA group) at the Cancer Institute Hospital, Tokyo, between January 2019 and May 2023. Propensity score matching (PSM) was performed to adjust for the possible confounding factors.

RESULTS

A total of 834 patients were initially included, of whom 614 (307 in each group) remained after PSM. The amylase levels in the drained abdominal fluid on postoperative days 1 and 3 were similar between the PGA and non-PGA groups. The PGA group had a significantly lower incidence of pancreas-related complications of Clavien-Dindo grade ≥2 than that in the non-PGA group (6.8% vs. 2.9%, P=0.025). In subgroup analyses, the odds ratio for pancreas-related complications appeared to be better in the PGA group than in the non-PGA group in patients with American Society of Anesthesiologists Physical Status Classification score of 2 or 3, those operated via a laparoscopic approach, and those undergoing procedures other than proximal gastrectomy.

CONCLUSIONS

The use of PGA mesh significantly reduced pancreas-related complications after minimally invasive surgery for gastric cancer and might thus benefit patients at risk of such complications.

Risk factors for postoperative pancreatic fistula (POPF) in gastric cancer patients: A systematic review and meta-analysis

BACKGROUND

Postoperative pancreatic fistula (POPF) is a common and serious consequence of gastrectomy. The prevalence of POPF among patients with gastric cancer varies greatly, and the risk factors and outcomes of POPF are also controversial. The meta-analysis aims to comprehensively assess the risk factors for POPF in gastric cancer patients.

METHODS

PubMed, Web of Science, the Cochrane Library, Embase, and Chinese databases (SinoMed, CNKI, WanFang, and VIP Databases) were searched to identify relevant studies (from inception to May 2023). Two researchers evaluated the literature quality and extracted data individually. The Review Manager 5.4 program was used to analyze all of the data.

RESULTS

In our meta-analysis, 22 studies totaling 11,647 patients were analyzed. Male sex (OR = 3.06), older age (OR = 3.22), body mass index (BMI) ≥ 25 kg/m2 (OR = 2.58), visceral fat area (VFA) ≥ 100 cm2 (OR = 3.65), pTNM Ⅲ-Ⅳ (OR = 2.47), the number of lymphlode dissections (OR = 1.04), neoadjuvant chemotherapy (NAC) (OR = 2.91), the application of LigaSure (OR = 3.30), open surgery (OR = 3.23), intraoperative combined organ resection (OR = 4.11), drainage amylase concentration on the first postoperative day (OR = 5.73) and C-reactive protein on the 3rd postoperative day ≥20 mg/dL (OR = 7.29) were the risk factors for POPF in gastric cancer patients. On the other hand, the operation time (OR = 1.34) was not a risk factor for POPF.

CONCLUSION

The frequency of POPF in people undergoing gastrectomy was determined by a variety of risk factors. Medical professionals should identify risk factors early and impose interventions to prevent them to lower the incidence of POPF in gastric cancer patients.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Robotic Gastrectomy Versus Laparoscopic Gastrectomy for Gastric Cancer: A Multicenter Cohort Study of 5402 Patients in China

OBJECTIVE

A large-scale multicenter retrospective cohort study was conducted to compare the short- and long-term outcomes of robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) for gastric cancer.

SUMMARY OF BACKGROUND DATA

RG is being increasingly used worldwide, but data from large-scale multicenter studies on the short- and long-term oncologic outcomes of RG versus LG are limited. The potential benefits of RG compared with LG for gastric cancer remain controversial.

METHODS

Data from eligible patients who underwent RG or LG for gastric cancer of 11 experienced surgeons from 7 centers in China between March 2010 and October 2019 were collected. The RG group was matched 1:1 with the LG group by using propensity score matching. The primary outcome was postoperative complications.

RESULTS

After propensity score matching, a well-balanced cohort of 3552 patients was included for further analysis. The occurrence of overall complications (12.6% vs 15.2%, P = 0.023) was lower in the RG group than in the LG group. RG was associated with less blood loss (126.8 vs 142.5 mL, P < 0.001) and more retrieved lymph nodes in total (32.5 vs 30.7, P < 0.001) and in suprapancreatic areas (13.3 vs 11.6, P < 0.001).The long-term oncological outcomes were comparable between the two groups.

CONCLUSIONS

The results of this multicenter study demonstrate that RG is a safe and effective treatment for gastric cancer when performed by experienced surgeons, although longer operation time and higher costs are still concerns about RG. This study provides evidence suggesting that RG may represent an alternative surgical treatment to LG.

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.

Robotic Distal Gastrectomy Reduces Drain Amylase Values in Patients With a Small Pancreas-left Gastric Artery Angle

PURPOSE

Pancreatic fistula is a severe complication after laparoscopic distal gastrectomy (LDG). We previously evaluated the pancreas-left gastric artery angle (PLA) as a risk indicator for developing a pancreatic fistula after LDG. This study evaluated the incidence of pancreatic fistula with robotic distal gastrectomy (RDG) in comparison to LDG from the view of the PLA.

MATERIALS AND METHODS

An association between the PLA and the incidence of pancreatic fistula in 165 patients who underwent either RDG (n=45) or LDG (n=120) was investigated retrospectively.

RESULTS

RDG patients had significantly lower drain amylase values (postoperative day 2) than LDG patients. As opposed to LDG patients, drain amylase values were similar for patients with small (PLA <62 degrees) and large (PLA ≥62 degrees) PLA in RDG patients.

CONCLUSION

Robotic surgery may reduce the risk of postoperative pancreatic fistula in patients with a small PLA.

A comparative study on perioperative outcomes between robotic versus laparoscopic D2 total gastrectomy

OBJECTIVE

Robotic surgery has been increasingly used worldwide owing to its advanced features. However, the significant benefits of robotic total gastrectomy (RTG) over laparoscopic total gastrectomy (LTG) have yet to be demonstrated. We conducted a prospective cohort study to compare the safety and efficacy of robotic and laparoscopic total gastrectomy (LTG) with D2 lymphadenectomy for AGC.

METHODS

Between March 26, 2018 and July 30, 2021, 155 patients between 18 and 80 years of age with locally advanced gastric cancer (cT2-4a, N0/+, M0) were enrolled. The perioperative outcomes within 30 days after surgery were compared between the RTG (n = 69) and LTG (n = 73) groups on a per-protocol (PP) basis. Postoperative complications were evaluated according to the Clavien-Dindo classification.

RESULTS

The overall postoperative morbidity rate was 21.74% in the RTG group and 28.77% in the LTG group with no significant difference (P = 0.44), RTG was associated with a lower incidence of pneumonia (4.35% vs. 15.07%, P = 0.047). No mortality was observed in either group. There was no significant difference in the total operative time (284.48 vs. 271.73 min, P = 0.171), but RTG was associated with a lower estimated volume of blood loss (110 vs. 150 ml, P < 0.001) and more total retrieved lymph nodes (LNs) (41.36 vs 35.1, P = 0.019), more extraperigastric LNs (14.91 vs. 12.19, P = 0.024) and more LNs in the suprapancreatic areas (14.68 vs. 11.82, P = 0.017). The laboratory data (amylase, inflammatory, Albumin and T lymphocyte levels) of the RTG group were better than those of the LTG group.

CONCLUSION

According to the results of this prospective cohort study, for patients with locally advanced gastric cancer, Robotic surgery has advantages over laparoscopic surgery for radical total gastrectomy with D2 lymphadenectomy performed by well-trained doctors.

Anatomy and assessment of a modified technique during totally robotic distal gastrectomy: A retrospective cohort study

Background

Robotic surgery has potential benefits in the management of gastric cancer patients. This study compares the outcomes between totally robotic distal gastrectomy (TRDG) with modified port placement and arm positioning technique and conventional totally laparoscopic distal gastrectomy (CTLDG).

Materials and methods

Fifty-two patients were enrolled into the study following a retrospective review of an in-patient database between January 2019 and June 2021. Patients who underwent gastric resection with the modified robotic technique were recruited into the study. Patients who did not receive treatment using the modified technique were excluded from the study. Data on demographic, clinical data and surgical outcomes were collected, analyzed, and presented. All statistical analyses were done using IBM SPSS statistical software.

Results

Nineteen patients were in the TRDG group, and their mean age was 60.42 ± 11.53 years. There were no differences in demographic characteristics (all p > 0.05); nonetheless, laparoscopic patients had a significantly higher preoperative albumin level (p = 0.000). The operative time was longer in the TRDG group (223min), but the difference was insignificant. The reconstruction time was significantly shorter for the laparoscopic group (p = 0.000). Except for a significantly higher value of postoperative albumin level (p-value = 0.005) in the robotic group, there were no significant differences in all other surgical outcomes between the two groups. One (5.3%) patient had a severe complication in the robotic group compared to four (12.1%) in the laparoscopic group. Nevertheless, the differences in complications were statistically insignificant.

Conclusion

The modified approach is a safe and feasible in totally robotic distal gastrectomy for the treatment of gastric cancer patients.

•

The modified approach has an acceptable operative time from the initial results.

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The short reconstruction time in laparoscopic group is ascribed to the surgeon's experience.

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The modified approach results in less blood loss, notwithstanding its statistical insignificance.

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The modified approach produces minimal surgical stress response witnessed by the levels of postoperative albumin.

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The modified technique produces less severe postoperative complications than conventional laparoscopic gastrectomy.

Analysis of the Occurrence of Diseases Following Gastrectomy for Early Gastric Cancer: a Nationwide Claims Study

Purpose

Various changes in nutrition, metabolism, immunity, and psychological status occur through multiple mechanisms after gastrectomy. The purpose of this study was to predict disease status after gastrectomy by analyzing diseases pattern that occur or change after gastrectomy.

Materials and Methods

A retrospective cohort study was conducted using nationwide claims data. Patients with gastric cancer who underwent gastrectomy or endoscopic resection were included in the study. Eighteen target diseases were selected and categorized based on their underlying mechanism. The incidence of each target disease was compared by dividing the study sample into those who underwent gastrectomy (cases) and those who underwent endoscopic resection for early gastric cancer (controls). The cases were matched with controls using propensity score matching. Thereafter, Cox proportional hazard models were used to evaluate intergroup differences in disease incidence after gastrectomy.

Results

A total of 97,634 patients who underwent gastrectomy (84,830) or endoscopic resection (12,804) were included. The incidence of cholecystitis (P<0.0001), pancreatitis (P=0.034), acute kidney injury (P=0.0083), anemia (P<0.0001), and inguinal hernia (P=0.0007) were higher after gastrectomy, while incidence of dyslipidemia (P<0.0001), vascular diseases (ischemic heart disease, stroke, and atherosclerosis; P<0.0001, P<0.0001, and P=0.0005), and Parkinson's disease (P=0.0093) were lower after gastrectomy.

Conclusions

This study identifies diseases that may occur after gastrectomy in patients with gastric cancer.

Hybrid Robotic and Laparoscopic Gastrectomy for Gastric Cancer: Comparison with Conventional Laparoscopic Gastrectomy

Purpose

The benefits of robotic gastrectomy remain controversial. We designed this study to elucidate the advantages of a hybrid robot and laparoscopic gastrectomy over conventional laparoscopic surgery.

Materials and Methods

A total of 176 patients who underwent gastrectomy for gastric cancer were included in this study. We compared 88 patients treated with hybrid robotic and laparoscopic gastrectomy (HRLG) and 88 patients who underwent conventional laparoscopic gastrectomy (CLG). In HRLG, suprapancreatic lymph node (LN) dissection was performed in a robotic setting. Clinicopathological characteristics, operative details, and short-term outcomes were analyzed for the patients.

Results

The number of LNs retrieved from the suprapancreatic area was significantly greater in the HRLG group (11.27±5.46 vs. 9.17±5.19, P=0.010). C-reactive protein levels were greater in the CLG group on both postoperative day (POD) 1 (5.11±2.64 vs. 4.29±2.38, P=0.030) and POD 5 (9.86±6.51 vs. 7.75±5.17, P=0.019). In addition, the neutrophil-to-lymphocyte ratio was significantly greater in the CLG group on both POD 1 (7.44±4.72 vs. 6.16±2.91, P=0.031) and POD 5 (4.87±3.75 vs. 3.81±1.87, P=0.020). Pulmonary complications occurred only in the CLG group (4/88 [4.5%] vs. 0/88 [0%], P=0.043).

Conclusions

HRLG is superior to CLG in terms of suprapancreatic LN dissection and postoperative inflammatory response.

Short-term Outcomes of Robotic Gastrectomy vs Laparoscopic Gastrectomy for Patients With Gastric Cancer: A Randomized Clinical Trial

Importance

Robotic gastrectomy (RG) for gastric cancer may be associated with decreased incidence of intra-abdominal infectious complications, including pancreatic fistula, leakage, and abscess. Prospective randomized clinical trials comparing laparoscopic gastrectomy (LG) and RG are thus required.

Objective

To compare the short-term surgical outcomes of RG with those of LG for patients with gastric cancer.

Design, Setting, and Participants

In this phase 3, prospective superiority randomized clinical trial of RG vs LG regarding reduction of complications, 241 patients with resectable gastric cancer (clinical stages I-III) were enrolled between April 1, 2018, and October 31, 2020.

Interventions

LG vs RG.

Main Outcomes and Measures

The primary end point was the incidence of postoperative intra-abdominal infectious complications. Secondary end points were incidence of any complications, surgical results, postoperative courses, and oncologic outcomes. The modified intention-to-treat population excluded patients who had been randomized and met the postrandomization exclusion criteria. There was also a per-protocol population for analysis of postoperative complications.

Results

This study enrolled 241 patients, with 236 patients in the modified intention-to-treat population (150 men [63.6%]; mean [SD] age, 70.8 [10.7] years). There was no significant difference in the incidence of intra-abdominal infectious complications (per-protocol population: 10 of 117 [8.5%] in the LG group vs 7 of 113 [6.2%] in the RG group). Of 241 patients, 122 were randomly assigned to the LG group, and 119 patients were randomly assigned to the RG group. Two of the 122 patients (1.6%) in the LG group converted from LG to open surgery, and 4 of 119 patients (3.4%) in the RG group converted from RG to open or laparoscopic surgery, with no significant difference. Finally, 117 patients in the LG group completed the procedure, and 113 in the RG group completed the procedure; these populations were defined as the per-protocol population. The overall incidence of postoperative complications of grade II or higher was significantly higher in the LG group (23 [19.7%]) than in the RG group (10 [8.8%]) (P = .02). Even in analysis limited to grade IIIa or higher, the complication rate was still significantly higher in the LG group (19 [16.2%]) than in the RG group (6 [5.3%]) (P = .01).

Conclusions and Relevance

This study found no reduction of intra-abdominal infectious complications with RG compared with LG for gastric cancer.

Trial Registration

umin.ac.jp/ctr Identifier: UMIN000031536.

Review on Perioperative and Oncological Outcomes of Robotic Gastrectomy for Cancer

BACKGROUND

Minimally invasive gastrectomy is currently considered a valid option to treat gastric cancer and is gaining increasing acceptance. Recent reports have suggested that the application of robots may confer some advantages over conventional laparoscopy, but the role of robotic surgery in clinical practice is still uncertain. We aimed to critically review the relevant evidence comparing robotic to standard laparoscopic surgery in performing radical gastrectomy.

METHODS

The Pubmed/Medline electronic databases were searched through February 2021. Paper conference and the English language was the only restriction applied to our search strategy.

RESULTS

According to the existing data, robotic gastrectomy seems to provide some benefits in terms of blood loss, rate of conversion, procedure-specific postoperative morbidity, and length of hospital stay. Robotic gastrectomy is also associated with a longer duration of surgery and a higher economic burden as compared to its laparoscopic counterpart. No significant differences have been disclosed in terms of long-term survivals, while the number of lymph nodes retrieved with robotic gastrectomy is generally higher than that of laparoscopy.

CONCLUSIONS

The current literature suggests that robotic radical gastrectomy appears as competent as the conventional laparoscopic procedure and may provide some clinical advantages. However, due to the relative paucity of high-level evidence, it is not possible to draw definitive conclusions.

Pancreatic Fistula after D1+/D2 Radical Gastrectomy according to the Updated International Study Group of Pancreatic Surgery Criteria: Risk Factors and Clinical Consequences. Experience of Surgeons with High Caseloads in a Single Surgical Center in Eastern Europe

Purpose

Incidence, risk factors, and clinical consequences of pancreatic fistula (POPF) after D1+/D2 radical gastrectomy have not been well investigated in Western patients, particularly those from Eastern Europe.

Materials and Methods

A total of 358 D1+/D2 radical gastrectomies were performed by surgeons with high caseloads in a single surgical center from 2002 to 2017. A retrospective analysis of data that were prospectively gathered in an electronic database was performed. POPF was defined and graded according to the International Study Group for Pancreatic Surgery (ISGPS) criteria. Uni- and multivariate analyses were performed to identify potential predictors of POPF. Additionally, the impact of POPF on early complications and long-term outcomes were investigated.

Results

POPF was observed in 20 patients (5.6%), according to the updated ISGPS grading system. Cardiovascular comorbidities emerged as the single independent predictor of POPF formation (risk ratio, 3.051; 95% confidence interval, 1.161–8.019; P=0.024). POPF occurrence was associated with statistically significant increased rates of postoperative hemorrhage requiring re-laparotomy (P=0.029), anastomotic leak (P=0.002), 90-day mortality (P=0.036), and prolonged hospital stay (P<0.001). The long-term survival of patients with gastric adenocarcinoma was not affected by POPF (P=0.661).

Conclusions

In this large series of Eastern European patients, the clinically relevant rate of POPF after D1+/D2 radical gastrectomy was low. The presence of co-existing cardiovascular disease favored the occurrence of POPF and was associated with an increased risk of postoperative bleeding, anastomotic leak, 90-day mortality, and prolonged hospital stay. POPF was not found to affect the long-term survival of patients with gastric adenocarcinoma.

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.

Predictive value of abdominal drain amylase for postoperative pancreatic fistula following gastric resection: A systematic review and meta-analysis

BACKGROUND

Radical dissection of lymph nodes, accompanying gastric cancer resection, can lead to collateral damage to the pancreas and development of postoperative pancreatic fistula (POPF).

METHODS

We searched the Cochrane Library, MEDLINE, Embase, and Web of Science up to April 21, 2020, to identify studies documenting the value of abdominal drain amylase level (d-AMY) on postoperative day 1 (POD1) as a predictor of POPF after gastric surgery. The quality of selected studies was assessed using the QUADAS-2 tool. The diagnostic value of d-AMY on POD1 for prediction of POPF was first assessed by calculation of pooled estimates of sensitivity, specificity, likelihood ratios (LR), and the diagnostic odds ratio (DOR). Secondly, the accuracy was further demonstrated graphically with the hierarchical summary receiver operating curve (hSROC). PROSPERO registration number: CRD42020181145.

RESULTS

DOR of nine studies (cases n = 1856) observing the occurrence of POPF after measurement of d-AMY on POD1 was 18.7 (95%CI: 10.0, 34.8), and the area under hSROC was 0.88 ± 0.02. The pooled sensitivity was 0.74 (95%CI: 0.66, 0.81) and specificity 0.84 (95%CI: 0.82, 0.86). The negative LR was at the lowest point of 0.16 (95%CI: 0.07, 0.37) at the cutoff value for d-AMY of 941 IU/L, while the positive LR ranged from 4.4 (cutoff 2119 IU/L) to 6.2 (cutoff 5000 IU/L).

CONCLUSION

d-AMY on POD1 can be used as an accurate and non-invasive predictor of POPF in the earliest stage of postoperative course following gastric cancer resection; value ≤ 941 IU/L warrants early drain removal and low probability of POPF (any grade).

Robotic-assisted gastrectomy for gastric cancer: single Western center results

A robotic approach to abdominal surgery procedures may improve postoperative outcomes compared to either open or laparoscopic approaches. The role of robotics for gastric surgery, however, is still being evaluated. A retrospective review of the prospectively maintained database for robotic gastric surgery at University of Siena between 2011 and 2020 was conducted. Data regarding surgical procedures, early postoperative outcomes, and long-term follow-up were analyzed. 38 patients underwent robotic partial or total gastrectomy. Conversion to open occurred in two patients (5.2%) due to locally advanced disease as well as difficult identification of primary lesion. Postoperative morbidity was 13.1% while no postoperative mortality was registered. The mean length of operation was 358.6 (220–650) minutes and the mean number of retrieved lymph nodes was 35.8 (range: 5–73). The median OS of all population was 70.9 months. The median 5-year OS for the patients with positive nodes was worse than that of patients without metastatic lymph nodes [51.4 months (95% CI 35.5–67.4) vs. 79.5 months (95% CI 67.1–91.8); p = 0.079]. The interesting results including postoperative morbidity as well as mortality rate, the surgical outcomes, and the 5-year OS, were to be acceptable considering the data recorded by previous studies on robotic gastrectomy. This study demonstrated that robotic gastrectomy is feasible and can be safely performed. However, further follow-up and randomized clinical trials are required to confirm the role of a robotic approach in gastric cancer surgery.

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.

Robotic- versus laparoscopic-assisted distal gastrectomy with D2 lymphadenectomy for advanced gastric cancer based on propensity score matching: short-term outcomes at a high-capacity center

Reports in the field of robotic surgery for gastric cancer are increasing. However, studies only on patients with advanced gastric cancer (AGC) are lacking. This retrospective study was to compare the short-term outcomes of robotic-assisted distal gastrectomy (RADG) and laparoscopic-assisted distal gastrectomy (LADG) with D2 lymphadenectomy for AGC. From December 2014 to November 2019, 683 consecutive patients with AGC underwent mini-invasive assisted distal gastrectomy. Propensity-score matching (PSM) analysis was conducted to reduce patient selection bias. Short-term outcomes were compared between the two groups. The clinical features were well matched in the PSM cohort. Compared with the LADG group, the RADG group was associated with less operative blood loss, a lower rate of postoperative blood transfusion, less volume of abdominal drainage, less time to remove abdominal drainage tube, retrieved more lymph node, and lower rates of surgical complications and pancreatic fistula (P <0.05). However, the time to recovery bowel function, the length of postoperative stay, the rates of other subgroups of complications and unplanned readmission were similar between the two groups (P > 0.05). This study suggests that RADG is a safe and feasible technique with better short-term outcomes than LADG for AGC.

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

Background

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

Methods

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

Results

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

Conclusions

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

Impact of high amylase level in drainage fluid after gastric cancer surgery: Is it a complication or suspicious biochemical measurement?

Purpose: Pancreatic fistula is a potential postoperative complication with variable definitions, incidences and risk factors. We intended to evaluate its impact after gastric surgery. Materials and Methods: A total of 28 consecutive patients who underwent curative open gastrectomy with lymphadenectomy for gastric adenocarcinoma were retrospectively analyzed. Patients’ demographics, peri-operative and pathological data were collected. Pancreatic fistula that was diagnosed and graded according to International Study Group of Pancreatic Fistula’s system was identified as main variable.Results: Mean age of patients was 58.8±10.1 years with a female to male ratio of 9/19. Grade A pancreatic fistula was diagnosed in six patients (21.4%). There was no grade B and C pancreatic fistula. Drain amylase level was significantly higher in patients with pancreatic fistula (p=0.0001). There was no significant difference with regard to amount of drainage, length of hospital stay and duration of drains in patients with and without fistula. No significant association was shown between development of fistula and patients’ demographics, peri-operative and pathological data. Conclusion: The development of grade A pancreatic fistula after gastric surgery does not appear to be a major complication with clinical consequences. High amylase level in the drainage fluid can be considered as a biochemical measure only.  

Robotic radical lymphadenectomy without touching the pancreas during gastrectomy for gastric cancer

Laparoscopic lymph node dissection around the peripancreatic area for gastric cancer (GC) remains challenging because of drawbacks in laparoscopic surgery including the limited range of movement, amplification of hand tremors, and inconvenient surgical positioning. In some cases of laparoscopic gastrectomy (LG), therefore, postoperative pancreatic fistula (POPF) occurs. Robotic surgery, on the other hand, plays an essential role in ergonomics and offers advantages, such as motion scaling, less fatigue, tremor filtering, 7 degrees of motion in the robotic instruments assisted by the wrist-like instruments tips, and three-dimensional vision. Robotic gastrectomy (RG) may enable surgeons to overcome the drawbacks associated with laparoscopic surgery. This study compares the safety and feasibility of short-term surgical outcomes of RG and LG for patients with GC.This was a single-center retrospective study of 659 consecutive patients with GC who received minimally invasive surgery. LG (n = 639) was performed between 2013 and 2017 and RG (n = 20) was performed in 2017. Lymphadenectomy without touching the pancreas was basically performed during RG using assisting articulating forceps.Overall incidence of postoperative complications higher than Clavien-Dindo grade 2 was not significantly different (LG group 5.9%, RG group 5.0%). In RG group, POPF, intra-abdominal abscess, and anastomotic leakage were not found, but postoperative bleeding requiring interventional catheter embolization occurred in 1 patient. In LG, POPF was found in 4.7%. Amylase levels in drainage fluid on postoperative day 1 were significantly lower in the RG group (238.5 IU/L) than in the LG group (884.5 IU/L) (P = .028).Regarding short-term surgical outcomes, RG is feasible, safe, and ideal treatment procedure for GC. Our robotic procedure without touching the pancreas may be associated with decreased incidence of POPF.

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.

Severity and incidence of complications assessed by the Clavien-Dindo classification following robotic and laparoscopic gastrectomy for advanced gastric cancer: a retrospective and propensity score-matched study

BACKGROUND

Robot-assisted gastrectomy (RAG) has been increasingly used for the treatment of advanced gastric cancer (AGC), and many advantages over laparoscopy-assisted gastrectomy (LAG) have been reported. However, its postgastrectomy complications still under investigation and the results remain controversial. This study aimed to objectively assess the incidence and severity of complications following RAG vs. LAG using Clavien-Dindo (C-D) classification and to identify risk factors related to complications.

METHODS

Five hundred and twenty-seven patients with AGC who underwent RAG or LAG between January 2016 and May 2018 were enrolled in this study. Complications were categorized according to the C-D classification. The complications following RAG and LAG were compared using one-to-one propensity score matching (PSM) analysis and subgroup analyses. Logistic regression analyses were performed to identify risk factors related to complications.

RESULTS

RAG was performed in 251 patients (47.6%) and LAG in 276 patients (52.4%). Before PSM, the RAG group had a smaller tumour size (P = 0.004) and less patients with previous abdominal operation (P = 0.013). After PSM, a well-balanced cohort of 446 patients (223 in each group) was further analyzed. Of interest, the incidence of overall and severe complications (C-D grade ≥ IIIa) following the RAG group were significantly fewer than the LAG group (overall, 24.5% vs. 18.8%, P < 0.001; severe, 8.9% vs. 17.5%, P = 0.002). Subgroup analyses showed statistically significant difference were also observed in most stratified parameters. Multivariable analysis identified age ≥ 65 years, total gastrectomy, stage T3-T4a, stage II-III, and operation time ≥ 250 min as independent predictors of overall complications. Additionally, age ≥ 65 years, stage II-III, and operation time ≥ 250 min were confirmed as independent risk factors for severe complications.

CONCLUSIONS

RAG with D2 lymphadenectomy is feasible and safe for the treatment of AGC in terms of the lower incidence and severity of complications.

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.

Comparison of Surgical Outcomes Between Robotic and Laparoscopic Distal Gastrectomy for cT1 Gastric Cancer

BACKGROUND

Increasing numbers of patients are treated by robotic distal gastrectomy (RDG); however, it remains unclear whether RDG is clinically comparable with conventional laparoscopic distal gastrectomy (LDG). This study aimed to clarify the feasibility of RDG from safety aspects.

METHODS

The study included 109 cT1 gastric cancer patients who underwent RDG at Shizuoka Cancer Center from January 2012 to April 2015. Short-term outcomes were compared with 160 cT1 gastric cancer patients who underwent LDG during the same period.

RESULTS

Patient characteristics were well matched. The RDG patients experienced longer operative times (323 min) than LDG patients (285 min; P < 0.001), although all other surgical outcomes were comparable between the groups. Drain amylase levels on POD 1 were significantly lower in the RDG group compared to LDG cases (median 452 U/L and 892 U/L; P < 0.001). The incidence of all complications was similar across the study patients, although intra-abdominal infectious complications tended to be lower in the RDG group than in the LDG group (2.8 and 8.1%; P = 0.112).

CONCLUSIONS

RDG was comparable to LDG in terms of feasibility for cT1 gastric cancer. RDG has the potential to reduce pancreas damage and thus to decrease intra-abdominal infectious complications.

Right-Side Approach-Duet Totally Laparoscopic Distal Gastrectomy (R-Duet TLDG) Using a Three-Port to Treat Gastric Cancer

BACKGROUND

Gastric cancer is commonly treated via minimally invasive surgery. The present study explored the feasibility of right-side approach-duet (R-duet) totally laparoscopic distal gastrectomy using a three-port compared with a four- or five-port.

METHODS

A total of 251 patients who underwent curative totally laparoscopic distal gastrectomy for gastric cancer (72 R-duet, 74 four-port, and 105 five-port) at the Catholic Medical Center were enrolled. All operations were performed using conventional laparoscopic instruments. The clinicopathological characteristics, operative details, and postoperative short-term outcomes were analyzed retrospectively.

RESULTS

The clinicopathological characteristics did not differ significantly among the groups, except that the N stage was higher in the five-port group. The operating time was significantly longer in the four-port than the R-duet group (R-duet, four-port, and five-port 148.2 ± 30.7, 162.4 ± 30.6, and 159.9 ± 31.5 min, respectively; p = 0.024). The estimated blood loss did not differ significantly. Postoperatively, the times to flatus and to soft diet consumption and the hospital stay were significantly longer in the five-port group. The extent of postoperative complications did not differ among the groups.

CONCLUSIONS

R-duet totally laparoscopic distal gastrectomy is a reliable form of reduced-port surgery when used to treat gastric cancer; no special instruments are required.

Robot-assisted distal gastrectomy with lymph node dissection for gastric cancer in a patient with situs inversus partialis: a case report with video file

BACKGROUND

Situs inversus is a rare congenital condition that is currently classified into two types: complete situs inversus (situs inversus totalis, SIT) and partial situs inversus (situs inversus partialis, SIP). In SIP patients, some organs are inverted and others are in their expected position, and individual patient variation in organ position increases surgical difficulty. Several surgeons have performed laparoscopic or robotic surgeries in situs inversus patients, but almost all were SIT patients. We report the first case, to our knowledge, of an SIP patient with gastric cancer who was successfully treated by robot-assisted distal gastrectomy (RADG) with lymph node dissection.

CASE PRESENTATION

A 64-year-old woman diagnosed with early gastric cancer on the posterior midbody of the stomach was referred to our hospital for treatment. Computed tomography showed levocardia and inverted abdominal organs without enlarged lymph nodes or distant metastases. Polysplenia syndrome, intestinal malrotation, and left-sided gallbladder were also detected. RADG with D1+ lymph node dissection and Billroth I reconstruction (delta-shaped anastomosis) were performed using robotics. Hepatopathy caused by a liver retractor and pancreatic fistula were identified during the postoperative course, and the latter was classified as grade II based on Clavien-Dindo classification. The patient was discharged 18 days after the operation.

CONCLUSIONS

Preoperative three-dimensional imaging is beneficial, and anatomical organ identification should be routinely performed, especially in SIP patients. We consider RADG a therapeutic option in SIP patients.

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.

Pancreas-related complications following gastrectomy: systematic review and meta-analysis of open versus minimally invasive surgery

BACKGROUND

Postoperative pancreas-related complications are quite uncommon but potentially life-threatening occurrences that may occasionally complicate the postoperative course of gastrectomy. A number of reports have described such conditions after both standard open and minimally invasive surgery. Our study has the purpose to systematically determine the pooled incidence of pancreatic events following radical gastrectomy. We also aimed to elucidate whether any difference in incidence exists between patients operated via conventional open or minimally invasive surgery.

METHODS

PubMed, EMBASE, and the Cochrane Library were systematically searched for randomized or well-matched studies comparing conventional with minimally invasive oncological gastrectomy and reporting pancreas-related postoperative complications. We evaluated possible differences in outcomes between open and minimally invasive surgery. A meta-analysis of relevant comparisons was performed using RevMan 5.3.

RESULTS

A total of 20 studies, whereby 6 randomized and 14 non-randomized comparative studies including a total of 7336 patients, were considered eligible for data extraction. Globally, more than 1% of patients experienced some pancreatic occurrences during the postoperative course. The use of minimally invasive surgery showed a trend toward increased overall pancreatic morbidity (OR 1.39), pancreatitis (OR 2.69), and pancreatic fistula (OR 1.13).

CONCLUSIONS

Although minimally invasive radical gastrectomy is currently established as a valid alternative to open surgery for the treatment of gastric cancer, a higher risk of pancreas-related morbidity should be taken into account.

Does postoperative morbidity worsen the oncological outcome after radical surgery for gastrointestinal cancers? A systematic review of the literature

PURPOSE

The impact of postoperative complications on survival after radical surgery for esophageal, gastric, and colorectal cancers remains controversial. We conducted a systematic review of recent publications to examine the effect of postoperative complications on oncological outcome.

METHODS

A literature search of PubMed/MEDLINE was performed using the keywords "esophageal cancer," "gastric cancer," and "colorectal cancer," obtaining 27 reports published online up until the end of April 2016. Articles focusing on (i) postoperative morbidity and oncological outcome; and (ii) body mass index (BMI), postoperative morbidity, and oncological outcome, were selected. Univariate and multivariate analyses (Cox proportional hazards model) were performed.

RESULTS

Patients with postoperative complications had significantly poorer long-term survival than those without complications. Complications were associated with impaired oncological outcomes. The hazard ratios for overall survival were 1.67 (95% confidence interval [CI], 1.31-2.12), 1.59 (95% CI, 1.13-2.24), and 1.55 (95% CI, 1.28-1.87) in esophageal, gastric, and colorectal cancers, respectively. High BMI was associated with postoperative morbidity rate but not with poor oncological outcome. Low BMI was significantly associated with inferior oncological outcome.

CONCLUSIONS

Complications after radical surgery for esophageal, gastric, and colorectal cancers are associated with patient prognosis. Avoiding such complications might improve the outcomes.

Robot-assisted laparoscopic gastrectomy for gastric cancer

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

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

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

The anatomical location of the pancreas is associated with the incidence of pancreatic fistula after laparoscopic gastrectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the major complications after laparoscopic gastrectomy (LG). We investigated the impact of the anatomical location of the pancreas, especially in relation to the suprapancreatic lymph nodes, on the incidence of POPF after LG.

METHODS

We retrospectively reviewed the preoperative computed tomography (CT) images of 246 patients who underwent LG with the suprapancreatic lymph node dissection between November 2008 and November 2015. The length between the levels of the pancreatic body surface and the root of the common hepatic artery (LPC) was measured on a CT image with an axial view. A receiver operating characteristics (ROC) curve analysis was performed to determine the cutoff LPC value. A multivariate analysis was performed to determine the predictive factors for POPF.

RESULTS

POPF occurred in 11 patients (4.5 %). The median LPC was significantly longer in the patients with POPF than in those without (26 mm vs. 21 mm, p = 0.026). The ROC curve analysis revealed that the optimal cutoff LPC value for predicting POPF was 25 mm. The POPF rate was significantly higher in the long LPC group than in the short LPC group (10 vs. 1.3 %, p = 0.002). A multivariate analysis demonstrated that a long LPC (p = 0.018) and dissection of the lymph nodes along the distal splenic artery (p = 0.042) were independent predictors of POPF. The amylase level in the drainage fluid on postoperative day 1 was significantly higher in the long LPC group than in the short LPC group.

CONCLUSIONS

The LPC is a simple and reliable predictor of POPF after LG. Surgeons should take the anatomical location of the pancreas into consideration when performing LG with suprapancreatic lymph node dissection.

Robotic surgery for gastric cancer

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