Robotic colon surgery in obese patients: a systematic review and meta-analysis

Robotic versus laparoscopic colorectal surgery for patients with obesity: an updated systematic review and meta-analysis

BACKGROUND

Obesity poses significant challenges in colorectal surgery, affecting operative difficulty and postoperative recovery. The choice of minimally invasive approach for this patient population remains a challenge during preoperative planning. This review aims to provide an updated synthesis of studies comparing laparoscopic and robotic approaches for adult patients with obesity undergoing colorectal surgery.

METHODS

MEDLINE, Embase and CENTRAL were searched up to August 2023. Articles were included if they compared laparoscopic and robotic colorectal surgery outcomes in adults with obesity (BMI ≥30 kg/m2). Outcomes included overall postoperative morbidity, conversion to laparotomy, and operative time. Inverse variance random-effects meta-analyses were used to pool effect estimates.

RESULTS

After screening 2187 citations, 10 observational studies were included with 3281 patients with obesity undergoing robotic surgery (mean age: 58.1 years, female: 43.9%) and 11 369 patients with obesity undergoing laparoscopic surgery (mean age: 58 years, female: 53.2%). Robotic surgery resulted in longer operative times (MD 46.71 min, 95% CI 33.50-59.92, p < 0.01, I2 = 93.79%) with statistically significant reductions in conversions to laparotomy (RR 0.50, 95% CI 0.39-0.65, p < 0.01, I2 = 67.15%). No significant differences were seen in postoperative morbidity (RR 0.94, 95% CI 0.82-1.08, p = 0.40, I2 = 36.08%).

CONCLUSION

These data suggest that robotic colorectal surgery in patients with obesity may reduce the risk for conversion to laparotomy, but at the expense of increased operative times and with no overt benefits in postoperative outcomes. Further high quality randomized controlled trials assessing the utility of robotic surgery in patients with obesity undergoing colorectal surgery are warranted.

A Review Article: The Relationship Between Obesity and Colorectal Cancer

PURPOSE OF REVIEW

This article aims to review the recent literature assessing the relationship between obesity and colorectal carcinogenesis, the effect of obesity on the treatment of colorectal cancer (CRC), tools available to help augment the increased risk, and outcomes for patients who are affected by both obesity and colorectal cancer.

RECENT FINDINGS

The biochemical mechanisms contributing to CRC carcinogenesis are not well understood but are suspected to be related to adipose tissue leading to a pro-inflammatory state and changes in the gut microbiome. Individuals with obesity are at higher risk for CRC development, worse oncologic outcomes, and increased rates of post-operative complications. Bariatric surgery decreases CRC risk but results with GLP-1 agonists are heterogeneous. Prehabilitation is the only weight loss method that has been demonstrated to decrease risks of post-operative morbidity in this population. Obesity augments CRC risk and outcomes. There are persistent knowledge gaps in etiology and epidemiology for the increased CRC risk in obese patients and more research is required to identify the therapeutic advantage of weight loss on CRC risk.

Robotic approach to colonic resection: For some or for all patients?

The robotic approach is rapidly gaining momentum in colorectal surgery. Its benefits in pelvic surgery have been extensively discussed and are well established amongst those who perform minimally invasive surgery. However, the same cannot be said for the robotic approach for colonic resection, where its role is still debated. Here we aim to provide an extensive debate between selective and absolute use of the robotic approach for colonic resection by combining the thoughts of experts in the field of robotic and minimally invasive colorectal surgery, dissecting all key aspects for a critical view on this exciting new paradigm in colorectal surgery.

Biochemical implications of robotic surgery: a new frontier in the operating room

Robotic surgery represents a milestone in surgical procedures, offering advantages such as less invasive methods, elimination of tremors, scaled motion, and 3D visualization. This in-depth analysis explores the complex biochemical effects of robotic methods. The use of pneumoperitoneum and steep Trendelenburg positioning can decrease pulmonary compliance and splanchnic perfusion while increasing hypercarbia. However, robotic surgery reduces surgical stress and inflammation by minimizing tissue trauma. This contributes to faster recovery but may limit immune function. Robotic procedures also limit ischemia-reperfusion injury and oxidative damage compared to open surgery. They also help preserve native antioxidant defenses and coagulation. In a clinical setting, robotic procedures reduce blood loss, pain, complications, and length of stay compared to traditional procedures. However, risks remain, including device failure, the need for conversion to open surgery and increased costs. On the oncology side, there is still debate about margins, recurrence, and long-term survival. The advent of advanced technologies, such as intraoperative biosensors, localized drug delivery systems, and the incorporation of artificial intelligence, may further improve the efficiency of robotic surgery. However, ethical dilemmas regarding patient consent, privacy, access, and regulation of this disruptive innovation need to be addressed. Overall, this review sheds light on the complex biochemical implications of robotic surgery and highlights areas that require additional mechanistic investigation. It presents a comprehensive approach to responsibly maximize the potential of robotic surgery to improve patient outcomes, integrating technical skill with careful consideration of physiological and ethical issues.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Colorectal Cancer and the Obese Patient: A Call for Guidelines

The link between obesity and colorectal cancer has been well established. The worldwide rise in obesity rates in the past 40 years means that we are dealing with increasing numbers of obese patients with colorectal cancer. We aimed to review the existing guidelines and make recommendations specific to this group of patients. Upon comparing the current NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®), the guidelines from the European Society of Medical Oncology (ESMO) and the guidelines of the Japanese Society for Cancer of the Colon and Rectum (JSCCR), we observed that these did not take into consideration the needs of obese patients. We proceeded to make specific recommendations with regards to the diagnostic work-up, surgical pathways, minimally invasive technique, perioperative treatment, post-operative surveillance, and management of metastatic disease in this group of patients. Our review highlights the need for modification of the existing guidelines to account for the needs of this patient cohort. A multidisciplinary approach, including principles used by bariatric surgeons, should be the way forward to reach consensus in the management of this group of patients.