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Qiu TH, Wen HY, Chen MM. Effect of double-tract reconstruction and laparoscopic proximal gastrectomy on immune function and stress. World J Gastrointest Surg 2025; 17:104192. [DOI: 10.4240/wjgs.v17.i6.104192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2025] [Revised: 03/07/2025] [Accepted: 05/07/2025] [Indexed: 05/30/2025] Open
Abstract
BACKGROUND Although surgery remains the primary treatment for proximal gastric cancer (PGC), ongoing refinements in surgical strategies are essential to improving clinical outcomes.
AIM To investigate the effect of double-tract reconstruction (DTR) on immune function and stress response in patients undergoing laparoscopic proximal gastrectomy (LPG).
METHODS In total, 78 patients with PGC admitted between August 2020 and August 2024 were enrolled. The research group consisted of 39 patients who underwent DTR + LPG, whereas the control group comprised 39 patients who underwent laparoscopic total gastrectomy with Roux-en-Y esophagojejunostomy. Perioperative indices (intraoperative blood loss, digestive tract anastomosis time, and time to first postoperative flatus), postoperative complications (intestinal obstruction, anastomotic ulcer, diarrhea, dumping syndrome, and gastroesophageal reflux), nutritional parameters (serum albumin, hemoglobin, and body mass index), immune function [immunoglobulin (Ig) G, IgA, and IgM), and stress response indicators (C-reactive protein, interleukin-6, and tumor necrosis factor-α) were collected and analyzed for both groups.
RESULTS The intraoperative blood loss was lower (P < 0.05), and the time to first postoperative flatus time was shorter (P < 0.001) in the research group than in the control group. The two groups had comparable digestive tract anastomosis time (P > 0.05). The overall complication rate was significantly lower in the research group than in the control group (P = 0.042). Compared with the control group, the research group exhibited notably higher albumin, hemoglobin, and body mass index levels at 2 and 3 months postoperatively, as well as considerably high immunoglobulin (Ig) G, IgA, and IgM levels on postoperative day 1 (P < 0.05). The postoperative levels of C-reactive protein, interleukin-6, and tumor necrosis factor-α were also lower in the research group than in the control group (P < 0.001).
CONCLUSION The combination of DTR and LPG in the treatment of patients with PGC is more effective in enhancing immune function and suppressing stress responses, showing more advantages over laparoscopic total gastrectomy.
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Affiliation(s)
- Ti-Hong Qiu
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu 611730, Sichuan Province, China
| | - Hong-You Wen
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu 611730, Sichuan Province, China
| | - Ming-Ming Chen
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu 611730, Sichuan Province, China
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Chen J, Wang F, Wang Y, Zhou J, Yang Y, Zhao Z, Wu R, Wang L, Ren J. A comparison of postoperative outcomes between robotic-assisted and laparoscopic-assisted total gastrectomy: a comprehensive meta-analysis and systematic review. BMC Surg 2025; 25:212. [PMID: 40375289 PMCID: PMC12079958 DOI: 10.1186/s12893-025-02934-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2024] [Accepted: 04/24/2025] [Indexed: 05/18/2025] Open
Abstract
BACKGROUND The application of robot-assisted technology in gastric cancer surgery is gradually gaining attention from surgeons. In this meta-analysis, our main objective was to assess whether robot-assisted techniques are more advantageous than laparoscopic-assisted technology in total gastrectomy. METHODS We searched Pubmed, Embase, Web of Science, and Cochrane Library databases for clinical studies published before October 2023 comparing robotic-assisted total gastrectomy (RATG) and laparoscopic-assisted total gastrectomy (LATG) for gastric cancer. Non-clinical studies, data unavailability, or fewer than 50 included cases were excluded. The Newcastle-Ottawa Scale was used to assess the risk of bias by determining the quality of the observational studies. Statistical meta-analysis and drawing were performed using the Software Review Manager version 5.3 and Stata version 16.0. P < 0.05 was considered significant. RESULTS Nine studies that included 1,864 patients with gastric cancer were included, published between 2012 and 2023. The results of the analysis showed that RATG has advantages in the following aspects: intraoperative blood loss was 17.69 ml lower in the RATG group than in the LATG group (WMD: -17.69,95% CI:-20.90 ∼ -14.49; P < 0.05); In terms of the number of resected lymph nodes, the RATG group had 2.65 more than the LATG group (WMD: 2.65,95% CI:0.88 ∼ -4.42); P < 0.05); the time to start liquid and postoperative hospital stays were 0.62 and 0.90 days shorter in the RATG group than in the LATG group, respectively (WMD: -0.62,95%CI: -1.06 ∼ -0.19; P < 0.05), (WMD: -0.90,95%CI: -1.43 ∼ -0.37; P < 0.05)); the incidence of major complications and pancreas fistula in the RATG group was 0.59% and 0.17% lower than in the LATG group, respectively (OR: 0.59,95% CI: 0.38 ∼ 0.93; P < 0.05), (OR: 0.17,95% CI: 0.03 ∼ 0.94; P < 0.05). However, the analysis showed that the operative time in the RATG group was 30.96 min longer than in the LATG group (WMD: 30.96,95% CI: 21.24 ∼ 40.69; P < 0.05). CONCLUSIONS Based on the results of this meta-analysis, we concluded that robotic-assisted technology may be a worthwhile technique to apply in the surgical treatment of total gastrectomy. However, this meta-analysis has the limitations that the included studies were all non-randomized controlled trials and published in Asian countries, and more high-quality randomized controlled trials are needed for further validation in the future. THE REGISTERED NAME AND REGISTRATION NUMBER The study protocol for this meta-analysis is registered on the PROSPERO website under registration number CRD42024500512.
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Affiliation(s)
- Jianhua Chen
- Department of General Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
- General Surgery Institute of Yangzhou, Northern Jiangsu People's Hospital, Yangzhou, People's Republic of China
| | - Fei Wang
- Department of Clinical Medical College, The Yangzhou School of Clinical Medicine, Dalian Medical University, Yangzhou, People's Republic of China
| | - Yong Wang
- Department of General Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
| | - Jie Zhou
- Department of Clinical Medical College, The Yangzhou School of Clinical Medicine, Dalian Medical University, Yangzhou, People's Republic of China
| | - Yapeng Yang
- Department of General Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
| | - Ziming Zhao
- Department of General Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
| | - Rongfan Wu
- Department of General Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
| | - Liuhua Wang
- Department of General Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, People's Republic of China
- General Surgery Institute of Yangzhou, Northern Jiangsu People's Hospital, Yangzhou, People's Republic of China
| | - Jun Ren
- Department of General Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China.
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, People's Republic of China.
- General Surgery Institute of Yangzhou, Northern Jiangsu People's Hospital, Yangzhou, People's Republic of China.
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Li R, Li J, Wang Y, Liu X, Xu W, Sun R, Xue B, Zhang X, Ai Y, Du Y, Jiang J. The artificial intelligence revolution in gastric cancer management: clinical applications. Cancer Cell Int 2025; 25:111. [PMID: 40119433 PMCID: PMC11929235 DOI: 10.1186/s12935-025-03756-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Accepted: 03/18/2025] [Indexed: 03/24/2025] Open
Abstract
Nowadays, gastric cancer has become a significant issue in the global cancer burden, and its impact cannot be ignored. The rapid development of artificial intelligence technology is attempting to address this situation, aiming to change the clinical management landscape of gastric cancer fundamentally. In this transformative change, machine learning and deep learning, as two core technologies, play a pivotal role, bringing unprecedented innovations and breakthroughs in the diagnosis, treatment, and prognosis evaluation of gastric cancer. This article comprehensively reviews the latest research status and application of artificial intelligence algorithms in gastric cancer, covering multiple dimensions such as image recognition, pathological analysis, personalized treatment, and prognosis risk assessment. These applications not only significantly improve the sensitivity of gastric cancer risk monitoring, the accuracy of diagnosis, and the precision of survival prognosis but also provide robust data support and a scientific basis for clinical decision-making. The integration of artificial intelligence, from optimizing the diagnosis process and enhancing diagnostic efficiency to promoting the practice of precision medicine, demonstrates its promising prospects for reshaping the treatment model of gastric cancer. Although most of the current AI-based models have not been widely used in clinical practice, with the continuous deepening and expansion of precision medicine, we have reason to believe that a new era of AI-driven gastric cancer care is approaching.
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Affiliation(s)
- Runze Li
- Hebei University of Traditional Chinese Medicine, Hebei, 050011, China
| | - Jingfan Li
- Hebei University of Traditional Chinese Medicine, Hebei, 050011, China
| | - Yuman Wang
- Hebei University of Traditional Chinese Medicine, Hebei, 050011, China
| | - Xiaoyu Liu
- Hebei University of Traditional Chinese Medicine, Hebei, 050011, China
| | - Weichao Xu
- Hebei University of Traditional Chinese Medicine, Hebei, 050011, China
- Hebei Hospital of Traditional Chinese Medicine, Hebei, 050011, China
| | - Runxue Sun
- Hebei Hospital of Traditional Chinese Medicine, Hebei, 050011, China
| | - Binqing Xue
- Hebei University of Traditional Chinese Medicine, Hebei, 050011, China
| | - Xinqian Zhang
- Hebei University of Traditional Chinese Medicine, Hebei, 050011, China
| | - Yikun Ai
- North China University of Science and Technology, Tanshan 063000, China
| | - Yanru Du
- Hebei Hospital of Traditional Chinese Medicine, Hebei, 050011, China.
- Hebei Provincial Key Laboratory of Integrated Traditional and Western Medicine Research on Gastroenterology, Hebei, 050011, China.
- Hebei Key Laboratory of Turbidity and Toxicology, Hebei, 050011, China.
| | - Jianming Jiang
- Hebei University of Traditional Chinese Medicine, Hebei, 050011, China.
- Hebei Hospital of Traditional Chinese Medicine, Hebei, 050011, China.
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4
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Wang QW, Leng J, Li W, Chen J. A comprehensive review and meta-analysis comparing robot-assisted and 3D laparoscopic gastrectomy for gastric cancer. J Robot Surg 2025; 19:96. [PMID: 40035959 DOI: 10.1007/s11701-024-02212-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2024] [Accepted: 12/30/2024] [Indexed: 03/06/2025]
Abstract
This review and meta-analysis evaluates the short-term surgical results of robot-assisted gastrectomy compared to 3D laparoscopic gastrectomy in individuals with gastric cancer. This study used scholarly articles from peer-reviewed articles of PubMed. Further, this study uses other sources, such as, Embase, CNKI, and the Cochrane Library, to gather relevant studies on gastrectomy for gastric cancer which are made public from the inception of these databases up to July 15, 2024. This study seeks to primarily draw similarities between the therapeutic efficacy of robot-assisted gastrectomy (RG) and the 3D laparoscopic gastrectomy (3D-LG). Similarly, this study will strictly adhere to the inclusion and exclusion guidelines, focusing on randomized controlled trials (RCTs) and cohort research. A total of 1231 gastric cancer patients were involved in incorporating seven retrospective cohort studies as the final analysis in the study with 533 undergoing robot-assisted gastrectomy and 698 undergoing 3D-LG. The results showed that patients who received robotic-assisted gastrectomy experienced superior outcomes regarding EBL and time-to-first postoperative exhaust compared to those who underwent 3D-LG. However, the robotic-assisted approach was related to a reduced number of LNY. Besides, there were similarities between the two surgical techniques in relation to OT, LOHS, and post-surgery complications. In summary, robot-assisted gastrectomy is acknowledged as a secure and efficient treatment option for individuals with stomach cancer. This approach demonstrated notable benefits compared to 3D-LG, particularly with regard to estimated intraoperative blood loss and the timing of the first postoperative exhaust.
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Affiliation(s)
- Qian-Wen Wang
- North Sichuan Medical College, Nanchong, Sichuan, China
- Department of General Surgery, 404 Hospital, Mian Yang, Sichuan Province, China
| | - Jun Leng
- North Sichuan Medical College, Nanchong, Sichuan, China
- Department of General Surgery, 404 Hospital, Mian Yang, Sichuan Province, China
| | - Wei Li
- North Sichuan Medical College, Nanchong, Sichuan, China
| | - Jin Chen
- Department of General Surgery, 404 Hospital, Mian Yang, Sichuan Province, China.
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Kossenas K, Moutzouri O, Georgopoulos F. Robotic vs laparoscopic distal gastrectomy with Billroth I and II reconstruction: a systematic review and meta-analysis. J Robot Surg 2024; 19:30. [PMID: 39699804 DOI: 10.1007/s11701-024-02193-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2024] [Accepted: 12/11/2024] [Indexed: 12/20/2024]
Abstract
Robotic distal gastrectomy (RDG) has been increasingly used for the treatment of gastric cancer, however, its comparative safety and efficacy against the laparoscopic approach (LDG), remains unclear, especially when accounting the reconstruction method as a confounder. This systematic review and meta-analysis aims to evaluate the short-term outcomes of RDG vs LDG In patIents with gastric cancer, undergoing Billroth I and II reconstruction. A systematic review was conducted in accordance with PRISMA guidelines. We searched Pubmed, Scopus and the Cochrane Library, up to October 22nd, 2024. The primary outcomes analyzed were the blood loss, operative duration, and the number of harvested lymph nodes and the secondary outcomes included overall complications, time to oral intake, duration of hospitalization and time to first flatus. Random-effects models were used to calculate weighted mean differences (WMD) and Odds ratios (OR) with 95% confidence intervals (CI), and heterogeneity was assessed using the I2 statistic. P values were also calculated. Sensitivity analysis was performed for outcomes with moderate to high heterogeneity. Five studies were included, involving 811 patients (RDG: n = 289, LDG: n = 522). RDG was associated with a significantly longer operative duration compared to LDG (WMD = 34.14 min, 95%CI 10.92 to 57.35, P = 0.004, I2 = 91%). RDG patients initiated oral intake earlier (WMD = -0.20 days, 95%CI -0.39 to -0.01, P = 0.03, I2 = 45%). RDG resulted in shorter hospital stays (WMD = -1.48 days, 95%CI -2.91 to -0.04, P = 0.04, I2 = 86%). RDG patients had a faster return to bowel function (time to first flatus) (WMD = -0.33 days, 95%CI -0.50 to -0.15, P = 0.00003, I2 = 57%). No statistically significant differences were observed regarding blood loss between RDG and LDG (WMD = -3.88 mL, 95%CI -21.63 to 13.87, P = 0.67, I2 = 78%). There was no statistically significant difference in complication rates (OR = 0.61, 95%CI 0.36 to 1.03, P = 0.06, I2 = 0%). No significant differences were observed regarding the number of lymph nodes harvested (WMD = -0.49, 95%CI -3.02 to 2.04, P = 0.70, I2 = 24%). Sensitivity analysis confirmed the robustness of the findings of operative duration and time to first flatus. RDG with BI/ BII requires longer operative duration, but it associated with faster recovery compared to LDG. No differences were observed between RDG and LDG with regards to overall complications, number of harvested lymph nodes and blood loss, showing that RDG is as safe and oncological equivalent to LDG. Future studies particularly, multi-center randomized clinical trials, should have a longer follow up period and examine the type of reconstruction separately. PROSPERO registration: CRD42024605895.
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Affiliation(s)
- Konstantinos Kossenas
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, 21 Ilia Papakyriakou, 2414 Engomi, P.O. Box 24005, 1700, Nicosia, Cyprus.
| | - Olga Moutzouri
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, 21 Ilia Papakyriakou, 2414 Engomi, P.O. Box 24005, 1700, Nicosia, Cyprus
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Chia DKA, Suda K, Ho WE, Lee BS, Suzuki K, Shibasaki S, Harada T, Murai J, Oe M, Asai H, Tomine T, Sato H, Yoro M, Ohashi M, Kitatsuji H, Green SP, Xiong Y, Shabbir A, Lomanto D, So JBY, Kim G, Uyama I. Feasibility of long-range telesurgical robotic radical gastrectomy in a live porcine model. Int J Surg 2024; 110:7720-7728. [PMID: 39806737 PMCID: PMC11634161 DOI: 10.1097/js9.0000000000002151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2024] [Accepted: 10/27/2024] [Indexed: 01/16/2025]
Abstract
BACKGROUND Telesurgery has been made increasingly possible with the advancements in robotic surgical platforms and network connectivity. However, long-distance transnational complex robotic surgeries such as gastrectomy have yet to be attempted. METHODS Multiple transnational network connections by Science Innovation Network (SINET), Japan Gigabit Network (JGN), and Arterial Research and Education Network in Asia-Pacific (ARENA-PAC) were established and tested by multiple surgeons in a dry box model. Surgeons' perceptions of the different networks were recorded. Three robotic radical D2 gastrectomies in live porcine models were performed at a hospital in Toyoake, Japan, by a surgical team in a hospital in Singapore ~5000 km away, using the hinotori Surgical Robot System (Medicaroid Corporation). RESULTS The live porcine robotic gastrectomies were all completed in under 205 min with no intraoperative complications. From the different networks that were tested, the differences in latency ranged from 107 to 132 ms and did not translate to any significant differences in surgeon timings and perceptions. CONCLUSIONS Transnational telesurgical radical D2 gastrectomy is feasible in a porcine model. There is no appreciable difference between surgeon performance and perception with network latencies of 107-132 ms. Long-range telesurgery as clinical practice may become possible in the future.
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Affiliation(s)
- Daryl Kai Ann Chia
- Department of Surgery, National University Hospital, Singapore, Singapore
- Centre for Obesity Management and Surgery, National University Hospital, Singapore, Singapore
| | - Koichi Suda
- Department of Surgery, Fujita Health University, Aichi, Japan
- Collaborative Laboratory for Research and Development in Advanced Surgical Intelligence, Fujita Health University, Aichi, Japan
| | - Wei-En Ho
- Ministry of Health Holdings, Singapore, Singapore
| | - Bu Sung Lee
- Singapore Advanced Research and Education Network (SingAREN), Singapore, Singapore
- School of Computer Science and Engineering, Nanyang Technological University, Singapore, Singapore
| | | | | | - Tatsuhiko Harada
- Department of Advanced Robotic and Endoscopic Surgery, Fujita Health University, Aichi, Japan
| | | | - Masafumi Oe
- National Astronomical Observatory of Japan, Mitaka, Tokyo, Japan
| | | | - Takashi Tomine
- National Astronomical Observatory of Japan, Mitaka, Tokyo, Japan
| | - Hirotaka Sato
- Asia-Pacific Advanced Network - Japan (APAN-JP), Japan
| | - Masahiro Yoro
- Medicaroid Asia Pacific Pte. Ltd., 9 Tampines Grande, Asia Green, Singapore, Singapore
| | - Masanao Ohashi
- Department of Product Marketing, Medicaroid Corporation, Hyogo, Japan
| | - Hiroaki Kitatsuji
- Department of Product Marketing, Medicaroid Corporation, Hyogo, Japan
- Medicaroid Corporation, Hyogo, Japan
| | - Simon Peter Green
- Singapore Advanced Research and Education Network (SingAREN), Singapore, Singapore
| | - Ying Xiong
- Singapore Advanced Research and Education Network (SingAREN), Singapore, Singapore
| | - Asim Shabbir
- Department of Surgery, National University Hospital, Singapore, Singapore
- Centre for Obesity Management and Surgery, National University Hospital, Singapore, Singapore
- Department of Surgery, National University of Singapore, Singapore, Singapore
| | - Davide Lomanto
- Department of Surgery, National University Hospital, Singapore, Singapore
- Centre for Obesity Management and Surgery, National University Hospital, Singapore, Singapore
- Department of Surgery, National University of Singapore, Singapore, Singapore
| | - Jimmy Bok Yan So
- Department of Surgery, National University Hospital, Singapore, Singapore
- Centre for Obesity Management and Surgery, National University Hospital, Singapore, Singapore
- Department of Surgery, National University of Singapore, Singapore, Singapore
| | - Guowei Kim
- Department of Surgery, National University Hospital, Singapore, Singapore
- Centre for Obesity Management and Surgery, National University Hospital, Singapore, Singapore
| | - Ichiro Uyama
- Department of Advanced Robotic and Endoscopic Surgery, Fujita Health University, Aichi, Japan
- Collaborative Laboratory for Research and Development in Advanced Surgical Technology, Fujita Health University, Aichi, Japan
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7
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Liu SS, Xie HY, Chang HD, Wang L, Yan S. Risk factors and prevention of pancreatic fistula after laparoscopic gastrectomy for gastric cancer. World J Gastrointest Surg 2024; 16:3413-3424. [PMID: 39649189 PMCID: PMC11622077 DOI: 10.4240/wjgs.v16.i11.3413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 08/06/2024] [Accepted: 08/16/2024] [Indexed: 10/30/2024] Open
Abstract
Following laparoscopic gastrectomy (LG), one of the critical complications that can arise is a pancreatic fistula (PF). The inability to promptly prevent, diagnose, and manage this condition can lead to severe complications and potentially be life-threatening for the patient. The incidence of PF post-LG in gastric cancer treatment is related to factors such as surgical approach, surgical instruments, characteristics of the pancreas itself, tumor stage, and the surgeon's experience. Currently, the diagnosis of postoperative PF is mainly based on the definition and diagnostic criteria consensus established by the International Study Group of Pancreatic Surgery. Gastrointestinal surgeons should be aware of the risk factors for PF, perform LG for gastric cancer with great care and precision, avoid pancreatic injury, and actively work to reduce the risk of postoperative PF.
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Affiliation(s)
- Shan-Shan Liu
- Department of Gastrointestinal Oncology Surgery, The Affiliated Hospital of Qinghai University, Xining 810000, Qinghai Province, China
| | - Hong-Yu Xie
- Department of Gastrointestinal Oncology Surgery, The Affiliated Hospital of Qinghai University, Xining 810000, Qinghai Province, China
| | - Hao-Dong Chang
- Department of Gastrointestinal Oncology Surgery, The Affiliated Hospital of Qinghai University, Xining 810000, Qinghai Province, China
| | - Liang Wang
- Department of Gastrointestinal Oncology Surgery, The Affiliated Hospital of Qinghai University, Xining 810000, Qinghai Province, China
| | - Su Yan
- Department of Gastrointestinal Oncology Surgery, The Affiliated Hospital of Qinghai University, Xining 810000, Qinghai Province, China
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8
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Yu X, Lei W, Zhu L, Qi F, Liu Y, Feng Q. Robotic versus laparoscopic distal gastrectomy for gastric cancer: A systematic review and meta-analysis. Asian J Surg 2024:S1015-9584(24)01268-5. [PMID: 38942631 DOI: 10.1016/j.asjsur.2024.06.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/19/2023] [Accepted: 06/19/2024] [Indexed: 06/30/2024] Open
Abstract
Distal gastrectomy (DG) with lymph node dissection for gastric cancer is routinely performed. In this meta-analysis, we present an updated overview of the perioperative and oncological outcomes of laparoscopic DG (LDG) and robotic DG (RDG) to compare their safety and overall outcomes in patients undergoing DG. An extensive search was conducted using the MEDLINE, EMBASE, PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials from the establishment of the database to June 2023 for randomized clinical trials comparing RDG and LDG. The primary outcome was operative results, postoperative recovery, complications, adequacy of resection, and long-term survival. We identified twenty studies, evaluating 5,447 patients (1,968 and 3,479 patients treated with RDG and LDG, respectively). We observed no significant differences between the two groups in terms of the proximal resection margin, number of dissected lymph nodes, major complications, anastomosis site leakage, time to first flatus, and length of hospital stay. The RDG group had a longer operative time (P < 0.00001), lesser bleeding (P = 0.0001), longer distal resection margin (P = 0.02), earlier time to oral intake (P = 0.02), fewer overall complications (P = 0.004), and higher costs (P < 0.0001) than the LDG group. RDG is a promising approach for improving LDG owing to acceptable complications and the possibility of radical resection. Longer operative times and higher costs should not prevent researchers from exploring new applications of robotic surgery.
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Affiliation(s)
- Xianzhe Yu
- Department of Gastrointestinal Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan Province, People's Republic of China; Lung Cancer Center, Lung Cancer Institute, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Wenyi Lei
- Department of Dermatology, The Second People's Hospital of Guiyang, Guiyang, Guizhou Province, People's Republic of China
| | - Lingling Zhu
- Lung Cancer Center, Lung Cancer Institute, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Fan Qi
- Department of Intensive Care Unit, The Second People's Hospital of Guiyang, Guiyang, Guizhou Province, People's Republic of China
| | - Yanyang Liu
- Lung Cancer Center, Lung Cancer Institute, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China.
| | - Qingbo Feng
- Department of General Surgery, Affiliated Hospital of Zunyi Medical University, Affiliated Digestive Hospital of Zunyi Medical University, Zunyi, Guizhou Province, People's Republic of China.
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9
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Manara M, Aiolfi A, Sozzi A, Calì M, Grasso F, Rausa E, Bonitta G, Bonavina L, Bona D. Short-Term Outcomes Analysis Comparing Open, Laparoscopic, Laparoscopic-Assisted, and Robotic Distal Gastrectomy for Locally Advanced Gastric Cancer: A Randomized Trials Network Analysis. Cancers (Basel) 2024; 16:1620. [PMID: 38730574 PMCID: PMC11083793 DOI: 10.3390/cancers16091620] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/16/2024] [Accepted: 04/20/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Minimally invasive surgery for the treatment of locally advanced gastric cancer (AGC) is debated. The aim of this study was to execute a comprehensive assessment of principal surgical treatments for resectable distal gastric cancer. METHODS Systematic review and randomized controlled trials (RCTs) network meta-analysis. Open (Op-DG), laparoscopic-assisted (LapAs-DG), totally laparoscopic (Lap-DG), and robotic distal gastrectomy (Rob-DG) were compared. Pooled effect-size measures were the risk ratio (RR), the weighted mean difference (WMD), and the 95% credible intervals (CrIs). RESULTS Ten RCTs (3823 patients) were included. Overall, 1012 (26.5%) underwent Lap-DG, 902 (23.6%) LapAs-DG, 1768 (46.2%) Op-DG, and 141 (3.7%) Rob-DG. Anastomotic leak, severe complications (Clavien-Dindo > 3), and in-hospital mortality were comparable. No differences were observed for reoperation rate, pulmonary complications, postoperative bleeding requiring transfusion, surgical-site infection, cardiovascular complications, number of harvested lymph nodes, and tumor-free resection margins. Compared to Op-DG, Lap-DG and LapAs-DG showed a significantly reduced intraoperative blood loss with a trend toward shorter time to first flatus and reduced length of stay. CONCLUSIONS LapAs-DG, Lap-DG, and Rob-DG performed in referral centers by dedicated surgeons have comparable short-term outcomes to Op-DG for locally AGC.
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Affiliation(s)
- Michele Manara
- I.R.C.C.S. Ospedale Galeazzi–Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157 Milan, Italy; (M.M.); (D.B.)
| | - Alberto Aiolfi
- I.R.C.C.S. Ospedale Galeazzi–Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157 Milan, Italy; (M.M.); (D.B.)
| | - Andrea Sozzi
- I.R.C.C.S. Ospedale Galeazzi–Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157 Milan, Italy; (M.M.); (D.B.)
| | - Matteo Calì
- I.R.C.C.S. Ospedale Galeazzi–Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157 Milan, Italy; (M.M.); (D.B.)
| | - Federica Grasso
- I.R.C.C.S. Ospedale Galeazzi–Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157 Milan, Italy; (M.M.); (D.B.)
| | - Emanuele Rausa
- I.R.C.C.S. Ospedale Galeazzi–Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157 Milan, Italy; (M.M.); (D.B.)
| | - Gianluca Bonitta
- I.R.C.C.S. Ospedale Galeazzi–Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157 Milan, Italy; (M.M.); (D.B.)
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, 20097 Milan, Italy;
| | - Davide Bona
- I.R.C.C.S. Ospedale Galeazzi–Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157 Milan, Italy; (M.M.); (D.B.)
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10
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Ri M, Ohashi M, Makuuchi R, Hayami M, Sano T, Nunobe S. Clinical Impact of Polyglycolic Acid Mesh to Reduce Pancreas-Related Complications After Minimally Invasive Surgery for Gastric Cancer: A Propensity Score Matching Analysis. J Gastric Cancer 2024; 24:220-230. [PMID: 38575514 PMCID: PMC10995823 DOI: 10.5230/jgc.2024.24.e17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/09/2024] [Accepted: 03/12/2024] [Indexed: 04/06/2024] Open
Abstract
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.
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Affiliation(s)
- Motonari Ri
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Manabu Ohashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Rie Makuuchi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masaru Hayami
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takeshi Sano
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Souya Nunobe
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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11
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Chan KS, Oo AM. Establishing the Learning Curve of Laparoscopic and Robotic Distal Gastrectomy: a Systematic Review and Meta-Regression Analysis. J Gastrointest Surg 2023; 27:2946-2982. [PMID: 37658172 DOI: 10.1007/s11605-023-05812-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/04/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Minimally invasive distal gastrectomy (MIDG) is non-inferior compared with open distal gastrectomy for gastric cancer. However, MIDG bears a learning curve (LC). This study aims to evaluate the number of cases required to surmount the LC (i.e. NLC) in MIDG. METHODS PubMed, Embase, Scopus, and the Cochrane Library were systematically searched from inception to August 2022 for studies which reported NLC in MIDG. NLC on reduced-port/single-port MIDG only were separately analysed. Poisson mean (95% confidence interval (CI)) was used to determine NLC. Negative binomial regression was used to compare NLC between laparoscopic distal gastrectomy (LDG) and robotic distal gastrectomy (RDG). RESULTS A total of 45 articles with 71 data sets (LDG n=47, RDG n=24) were analysed. There were 7776 patients in total (LDG n=5516, RDG n=2260). Majority of studies were conducted in East Asia (n=68/71). Majority (76.1%) of data sets used non-arbitrary methods of analyses. The overall NLC for RDG was significantly lower compared to LDG (RDG 22.4 (95% CI: 20.4-24.5); LDG 46.7 (95% CI: 44.1-49.4); incidence rate ratio 0.48, p<0.001). The median number of laparoscopic gastrectomy (LG) cases prior was 0 (interquartile range (IQR) 0-105) for LDG and 159 (IQR 101-305.3) for RDG. Meta-regression analysis did not show a significant impact prior experience in LG, extent of lymphadenectomy and intracorporeal vs extracorporeal anastomosis had on overall NLC for LDG and RDG. CONCLUSION NLC for RDG is shorter compared to LDG, but this may be due to prior experience in LG and ergonomic advantages of RDG.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| | - Aung Myint Oo
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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12
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Kossenas K, Georgopoulos F. The Evolving Surgical Landscape: A Comprehensive Review of Robotic Versus Laparoscopic Gastrectomy for the Treatment of Gastric Cancer. Cureus 2023; 15:e49780. [PMID: 38161532 PMCID: PMC10757755 DOI: 10.7759/cureus.49780] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
Robotic gastrectomy has been gaining ground in the past 20 years. This study aims to (a) provide an updated and all-encompassing comprehensive review including post-operative outcomes, rate of complications, surgical efficiency and costs, pathology, overall survival, mortality and recurrence, and disease-free survival of robotic versus laparoscopic gastrectomy, (b) report research gaps, and (c) identify ongoing or forthcoming clinical trials that could potentially shed light on underreported findings within the existing literature. Regarding the methodology, PubMed and Google Scholar were searched for randomized controlled trials, systematic reviews, and meta-analyses published between January 2012 and October 2023. ClinicalTrials.gov was searched for related clinical trials currently underway or recruiting. Robotic gastrectomy, when compared to laparoscopic gastrectomy, for the treatment of gastric cancer, performs equally well or shows superiority in terms of the length of hospitalization, overall complications rates, rate of conversion to open surgery, surgical complications, anastomotic leakage, pancreatic complications, blood loss, mortality rates, time to first flatus, time to oral intake, distal and proximal resection margins, recurrence rate, reoperation rates, and overall survival. However, it is associated with higher costs and longer operative time. Parameters such as duodenal stump leakage, anastomosis stenosis, intestinal obstruction, ileus, delayed gastric emptying, wound complications, acute pancreatitis, pancreatic fistula, direct costs, time to initiation of adjuvant chemotherapy, postoperative morbidity, recurrence, and disease-free survival are currently underreported in the literature and necessitate for further research. Lastly, four clinical trials are currently underway or recruiting that could possibly bridge the research gap.
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13
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Zhang B, Zhu Q, Ji ZP. Nomogram for predicting early complications after distal gastrectomy. World J Gastrointest Surg 2023; 15:2500-2512. [PMID: 38111768 PMCID: PMC10725534 DOI: 10.4240/wjgs.v15.i11.2500] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/04/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Reducing or preventing postoperative morbidity in patients with gastric cancer (GC) is particularly important in perioperative treatment plans. AIM To identify risk factors for early postoperative complications of GC post-distal gastrectomy and to establish a nomogram prediction model. METHODS This retrospective study included 131 patients with GC who underwent distal gastrectomy at the Second Hospital of Shandong University between January 2019 and February 2023. The factors influencing the development of complications after distal gastrectomy in these patients were evaluated using univariate and multivariate logistic regression analysis. Based on the results obtained, a predictive nomogram was established. The nomogram was validated using internal and external (n = 45) datasets. Its sensitivity and specificity were established by receiver operating characteristic curve analysis. Decision curve (DCA) analysis was used to determine its clinical benefit and ten-fold overfitting was used to establish its accuracy and stability. RESULTS Multivariate logistic regression analysis showed that hypertension, diabetes, history of abdominal surgery, and perioperative blood transfusion were independent predictors of postoperative complications of distal gastrectomy. The modeling and validation sets showed that the area under the curve was 0.843 [95% confidence interval (CI): 0.746-0.940] and 0.877 (95%CI: 0.719-1.000), the sensitivity was 0.762 and 0.778, respectively, and the specificity was 0.809 and 0.944, respectively, indicating that the model had good sensitivity and specificity. The C-indexes of the modeling and validation datasets were 0.843 (95%CI: 0.746-0.940) and 0.877 (95%CI: 0.719-1.000), respectively. The calibration curve (Hosmer Lemeshow test: χ2 = 7.33) showed that the model had good consistency. The results of the DCA analysis indicated that this model offered good clinical benefits. The accuracy of 10-fold cross-validation was 0.878, indicating that the model had good accuracy and stability. CONCLUSION The nomogram prediction model based on independent risk factors related to postoperative complications of distal gastrectomy can facilitate perioperative intervention for high-risk populations and reduce the incidence of postoperative complications.
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Affiliation(s)
- Biao Zhang
- Department of Gastrointestinal Surgery, Second Hospital of Shandong University, Jinan 250033, Shandong Province, China
| | - Qing Zhu
- Department of Gastrointestinal Surgery, Second Hospital of Shandong University, Jinan 250033, Shandong Province, China
| | - Zhi-Peng Ji
- Department of Gastrointestinal Surgery, Second Hospital of Shandong University, Jinan 250033, Shandong Province, China
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14
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Lu J, Wu D, Huang JB, Lin J, Xu BB, Xue Z, Zheng HL, Lin GS, Shen LL, Li P, Wang JB, Lin JX, Chen QY, Cao LL, Xie JW, Zheng CH, Huang CM. Comparison of robotic versus laparoscopic versus open distal gastrectomy for locally advanced gastric cancer: a prospective trial-based economic evaluation. Surg Endosc 2023; 37:7472-7485. [PMID: 37395806 DOI: 10.1007/s00464-023-10147-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/20/2023] [Indexed: 07/04/2023]
Abstract
IMPORTANCE It is largely unclear whether robotic distal gastrectomy (RDG) is cost-effective for locally advanced gastric cancer (LAGC). OBJECTIVE To evaluate the cost-effectiveness of RDG, laparoscopic distal gastrectomy (LDG), and open distal gastrectomy (ODG) for patients with LAGC. DESIGN, SETTING, AND PARTICIPANTS Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. A decision-analytic model was constructed to evaluate the cost-effectiveness of RDG, LDG, and ODG. EXPOSURES RDG, LDG, and ODG. MAIN OUTCOMES AND MEASURES Incremental cost-effectiveness ratio (ICER) and quality-adjusted life year (QALY). RESULTS This pooled analysis of two randomized controlled trials included 449 patients: 117, 254, and 78 patients in the RDG, LDG, and ODG groups, respectively. After IPTW, RDG demonstrated its priority in terms of less blood loss, postoperative length, and complication rate (all P < 0.05). RDG also showed higher QOL with more cost, representing an ICER of $85,739.73 per QALY and $42,189.53 per QALY compared to LDG and ODG, respectively. In probabilistic sensitivity analysis, RDG achieved the best cost-effectiveness for patients with LAGC only when the willingness-to-pay threshold was > $85,739.73 per QALY, which significantly exceeded 3 times Chinese per capita GDP. Furthermore, one of the most important factors was the indirect costs of robotic surgery in terms of the cost-effectiveness of RDG compared to that of LDG or ODG. CONCLUSIONS AND RELEVANCE Although improved short-term outcomes and QOL were seen in patients underwent RDG, the economic burden should be considered in the clinical decision-making regarding robotic surgery use for patients with LAGC. Our findings may vary in different health care settings and affordability. Trial registration CLASS-01 trial (ClinicalTrials.gov, CT01609309) and FUGES-011 trial (ClinicalTrials.gov, NCT03313700).
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Affiliation(s)
- Jun Lu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Dong Wu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jiao-Bao Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jia Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Bin-Bin Xu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhen Xue
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hua-Long Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Guo-Sheng Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Li-Li Shen
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ping Li
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jia-Bin Wang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jian-Xian Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qi-Yue Chen
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Long-Long Cao
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jian-Wei Xie
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Chao-Hui Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Chang-Ming Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
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15
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Fujimoto D, Taniguchi K, Takashima J, Kobayashi H. Indocyanine Green Tracer-Guided Radical Robotic Distal Gastrectomy Using the Firefly™ System Improves the Quality of Lymph Node Dissection in Patients with Gastric Cancer. J Gastrointest Surg 2023; 27:1804-1811. [PMID: 37308737 DOI: 10.1007/s11605-023-05740-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/03/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND This study investigated indocyanine green (ICG) as an intraoperative tool for improving lymph node dissection quality in radical robotic distal gastrectomy (RDG) for gastric cancer by comparing the rate of lymph node (LN) noncompliance with or without use of the Firefly™ system. METHODS Patients with potentially resectable gastric cancer including cT1-T4a, N0/ + , M0 were registered in a prospective nonrandomized cohort study at our institution between March 2019 and December 2022. Patients were assigned to the da Vinci surgical system with Firefly system (F group) or that without Firefly system (non-F group). F group patients received endoscopic peritumoral injection of ICG to the submucosa one day before surgery. Rate of LN noncompliance, number of harvested LNs, and short-term outcomes were compared. RESULTS Of the 94 patients in this study, 55 underwent Firefly system-guided RDG and 39 underwent conventional RDG. The mean [SD] total number of harvested lymph nodes in F group, 31.2 [10.2], was significantly higher than that harvested in non-F group (25.6 [12.6]; p = 0.026). The LN noncompliance rate in F group was lower than that in non-F group (32.7% vs. 61.5%, p = 0.006). The mean number of LNs harvested in F group was significantly higher than that harvested in non-F group (31.2 [10.2] vs. 25.7 [12.6], p = 0.02). Significant differences were found between the F vs. non-F groups in blood loss and postoperative hospital stay (83.9 [75.1] vs. 301.9 [766.7] mL; p = 0.003 and 13.4 vs. 17.4 days, p = 0.049). CONCLUSION The Firefly system-assisted ICG tracer improved LN dissection quality without compromising safety.
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Affiliation(s)
- Daisuke Fujimoto
- Department of Surgery, Teikyo University Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-Ku, Kawasaki-City, Kanagawa, 213-8507, Japan.
| | - Keizo Taniguchi
- Department of Surgery, Teikyo University Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-Ku, Kawasaki-City, Kanagawa, 213-8507, Japan
| | - Junpei Takashima
- Department of Surgery, Teikyo University Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-Ku, Kawasaki-City, Kanagawa, 213-8507, Japan
| | - Hirotoshi Kobayashi
- Department of Surgery, Teikyo University Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-Ku, Kawasaki-City, Kanagawa, 213-8507, Japan
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16
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Loureiro P, Barbosa JP, Vale JF, Barbosa J. Laparoscopic Versus Robotic Gastric Cancer Surgery: Short-Term Outcomes-Systematic Review and Meta-Analysis of 25,521 Patients. J Laparoendosc Adv Surg Tech A 2023; 33:782-800. [PMID: 37204324 DOI: 10.1089/lap.2023.0136] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
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.
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Affiliation(s)
- Pedro Loureiro
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - José Pedro Barbosa
- Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Stomatology, São João University Hospital Center, Porto, Portugal
| | | | - José Barbosa
- Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of General Surgery, São João University Hospital Center, Porto, Portugal
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17
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Chan KS, Shelat VG. Three-Dimensional Versus Two-Dimensional Laparoscopy in Laparoscopic Liver Resection: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2023; 33:678-690. [PMID: 37057963 DOI: 10.1089/lap.2023.0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
Background: Three-dimensional (3D) laparoscopy provides stereopsis and may reduce operating time (OT) and morbidity. However, there is a paucity of literature on its use in laparoscopic liver resection (LLR). This study aims to compare outcomes between 3D and two-dimensional (2D) LLR. Materials and Methods: PubMed, Embase, Scopus, and the Cochrane Library were systematically searched from inception to November 2022. The inclusion criterion was studies comparing intraoperative characteristics and/or postoperative outcomes between 3D and 2D LLR. Studies on the use of 3D image reconstruction techniques for preoperative planning were excluded. Primary outcomes were OT, estimated blood loss (EBL), and overall morbidity. Secondary outcomes were other postoperative complications, need for reoperation, and in-hospital mortality. Results: Four studies with 361 patients (3D: n = 159, 2D: n = 202) were included. There were 65.3% males (overall: n = 236/361). Age, sex, body-mass index, incidence of diabetes mellitus, hepatitis B and/or C carrier, receipt of neoadjuvant chemotherapy, tumor size, and incidence of multiple tumors were comparable between 3D and 2D LLR. No studies reported on Child-Pugh status. One study included only patients with hepatocellular carcinoma, two studies included patients with mixed histopathology, and one study did not report on histopathology. There was no significant difference in OT (mean difference [MD] -31.6 minutes, 95% confidence interval [CI]: -89.7 to 26.5), EBL (MD -454.1 mL, 95% CI: -978.8 to 70.6), need for reoperation (odds ratio [OR] 0.91, 95% CI: 0.18-4.61), and in-hospital mortality (OR 0.52, 95% CI: 0.06-5.50) between 3D and 2D LLR. Overall morbidity was lower in 3D LLR (OR 0.56, 95% CI: 0.32-0.98, P = .04). However, the learning curve (LC) was not described in the included studies and may confound outcomes. Conclusions: 3D LLR may reduce overall postoperative morbidity compared with 2D LLR, but results may be confounded by the lack of standardization of surgeons' experience and the LC of 3D LLR.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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18
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Suda K, Sakai M, Obama K, Yoda Y, Shibasaki S, Tanaka T, Nakauchi M, Hisamori S, Nishigori T, Igarashi A, Noshiro H, Terashima M, Uyama I. Three-year outcomes of robotic gastrectomy versus laparoscopic gastrectomy for the treatment of clinical stage I/II gastric cancer: a multi-institutional retrospective comparative study. Surg Endosc 2023; 37:2858-2872. [PMID: 36484859 DOI: 10.1007/s00464-022-09802-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Oncological benefits of robotic gastrectomy (RG) remain unclear. We aimed to determine and compare the 3-year outcomes of RG and laparoscopic gastrectomy (LG) for the treatment of gastric cancer. METHODS This was a multi-institutional retrospective study of patients who prospectively underwent RG in a previous study (UMIN000015388) and historical controls who underwent LG. Operable patients with cStage I/II primary gastric cancer were enrolled. The inverse probability of treatment weighting method based on propensity scores was used to balance patient demographic factors and surgeon volume between the RG and LG groups. The primary outcome measure was the 3-year overall survival rate (3yOS). RESULTS Of the 1,127 patients in the previous study, 326 and 752 patients in the RG and LG groups, respectively, completed the study. The standardized difference of all confounding factors was reduced to 0.09 or less after weighting. In the weighted population, 3yOS was 96.3% and 89.6% in the RG and LG groups, respectively (hazard ratio [HR] 0.34 [0.15, 0.76]; p = 0.009), whereas there was no difference in 3-year recurrence-free survival rate (3yRFS) between the two groups (HR 0.58 [0.32, 1.05]; p = 0.073). Sub-analyses showed that RG improved 3yOS (HR 0.05 [0.01, 0.38]; p = 0.004) and 3yRFS (HR 0.05 [0.01, 0.34]; p = 0.003) in patients with pStage IA disease. Recurrence rates and patterns were similar between the RG and LG groups. RG did not improve the morbidity rate, however, it attenuated some of the adverse events, including anastomotic leakage and intra-abdominal abscess. RG improved estimated blood loss and duration of postoperative hospitalization. CONCLUSION This study showed surgical and oncological safety of RG for cStage I/II gastric cancer considering the 3-year outcomes, compared with those of LG.
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Affiliation(s)
- Koichi Suda
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan.
- Collaborative Laboratory for Research and Development in Advanced Surgical Intelligence, Fujita Health University, Toyoake, Japan.
| | | | - Kazutaka Obama
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yukie Yoda
- Department of Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Susumu Shibasaki
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Tsuyoshi Tanaka
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Masaya Nakauchi
- Department of Advanced Robotic and Endoscopic Surgery, Fujita Health University, Toyoake, Japan
| | - Shigeo Hisamori
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tatsuto Nishigori
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ataru Igarashi
- Unit of Public Health and Preventive Medicine, Yokohama City University School of Medicine, Yokohama, Japan
- Department of Health Economics and Outcomes Research, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Hirokazu Noshiro
- Department of Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | | | - Ichiro Uyama
- Department of Advanced Robotic and Endoscopic Surgery, Fujita Health University, Toyoake, Japan
- Collaborative Laboratory for Research and Development in Advanced Surgical Technology, Fujita Health University, Toyoake, Japan
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19
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Sun T, Wang Y, Liu Y, Wang Z. Perioperative outcomes of robotic versus laparoscopic distal gastrectomy for gastric cancer: a meta-analysis of propensity score-matched studies and randomized controlled trials. BMC Surg 2022; 22:427. [DOI: 10.1186/s12893-022-01881-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022] Open
Abstract
Abstract
Background
Da Vinci robotic surgery system, a novel type of surgery, was widespread in surgical field. However, the perioperative outcomes of robotic distal gastrectomy (RDG) are still controversy, despite several observational studies and randomized controlled trials (RCT) had been reported. Therefore, we performed a meta-analysis of propensity score-matched (PSM) and RCT studies to evaluated the perioperative feasibility and safety of RDG.
Methods
Studies were systematically searched in PubMed, Web of Science, Cochrane Library, and Embase database, and screened according to the defined limitations. The quality of PSM studies and RCT studies were respectively assessed by ROBINS-I and Cochrane risk-of-bias tool. Extracted data were analyzed by Review Manager 5.4.
Results
7 PSM studies and 1 RCT with a total of 2763 patients were included in this analysis. The longer operative time (MD = 31.42, 95% CI [22.88, 39.96], p < 0.00001), less blood loss (MD = − 25.89, 95% CI [− 36.18, − 15.6], p < 0.00001), more retrieved lymph nodes (MD = 3.46, 95% CI [2.94, 3.98], p < 0.00001), shorter time to first flatus (MD = − 0.08, 95% CI [− 0.13, − 0.02], p = 0.006) and liquid intake (MD = − 0.13, 95% CI [− 0.22, − 0.05], p = 0.002) were observed in RDG group compared with LDG group. There are no statistically significant in time to start soft diet, postoperative hospital stays, overall complications, complications Grade I–II, complications Grade ≥ III, anastomotic leakage, bleeding, intra-abdominal bleeding, intraluminal bleeding, ileus, abdominal infection, delayed gastric emptying and wound complications.
Conclusions
RDG showed less blood loss and more retrieved lymph nodes, revealed less time to first flatus and liquid intake after operation. But the operative time was longer in RDG group than in LDG. The incidence rate of postoperative complications was comparable between RDG and LDG.
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Rosa F, Schena CA, Laterza V, Quero G, Fiorillo C, Strippoli A, Pozzo C, Papa V, Alfieri S. The Role of Surgery in the Management of Gastric Cancer: State of the Art. Cancers (Basel) 2022; 14:cancers14225542. [PMID: 36428634 PMCID: PMC9688256 DOI: 10.3390/cancers14225542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022] Open
Abstract
Surgery still represents the mainstay of treatment of all stages of gastric cancer (GC). Surgical resections represent potentially curative options in the case of early GC with a low risk of node metastasis. Sentinel lymph node biopsy and indocyanine green fluorescence are novel techniques which may improve the employment of stomach-sparing procedures, ameliorating quality of life without compromising oncological radicality. Nonetheless, the diffusion of these techniques is limited in Western countries. Conversely, radical gastrectomy with extensive lymphadenectomy and multimodal treatment represents a valid option in the case of advanced GC. Differences between Eastern and Western recommendations still exist, and the optimal multimodal strategy is still a matter of investigation. Recent chemotherapy protocols have made surgery available for patients with oligometastatic disease. In this context, intraperitoneal administration of chemotherapy via HIPEC or PIPAC has emerged as an alternative weapon for patients with peritoneal carcinomatosis. In conclusion, the surgical management of GC is still evolving together with the multimodal strategy. It is mandatory for surgeons to be conscious of the current evolution of the surgical management of GC in the era of multidisciplinary and tailored medicine.
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Affiliation(s)
- Fausto Rosa
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Carlo Alberto Schena
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Vito Laterza
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Correspondence:
| | - Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Antonia Strippoli
- Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Carmelo Pozzo
- Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Valerio Papa
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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21
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Zizzo M, Zanelli M, Sanguedolce F, Torricelli F, Morini A, Tumiati D, Mereu F, Zuliani AL, Palicelli A, Ascani S, Giunta A. Robotic versus Laparoscopic Gastrectomy for Gastric Cancer: An Updated Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060834. [PMID: 35744096 PMCID: PMC9231199 DOI: 10.3390/medicina58060834] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/08/2022] [Accepted: 06/14/2022] [Indexed: 12/13/2022]
Abstract
Background and Objectives: Gastrectomy with D2 lymphadenectomy is the standard surgical treatment with curative intent for patients with gastric cancer (GC). Over the last three decades, surgeons have been increasingly adopting laparoscopic surgery for GC, due to its better short-term outcomes. In particular, laparoscopic gastrectomy (LG) has been routinely used for early gastric cancer (EGC) treatment. However, LG suffers from technical limitations and drawbacks, such as a two-dimensional surgical field of view, limited movement of laparoscopic tools, unavoidable physiological tremors and discomfort for operating surgeon. Therefore, robotic surgery has been developed to address such limitations. Materials and Methods: We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines in order to investigate the benefits and harms of robotic gastrectomy (RG) compared to the LG. PubMed/MEDLINE, Scopus, Cochrane Library (Cochrane Database of Systematic Re-views, Cochrane Central Register of Controlled Trials-CENTRAL) and Web of Science (Science and Social Science Citation Index) databases were used to search all related literature. Results: The 7 included meta-analyses covered an approximately 20 years-study period (2000-2020). Almost all studies included in the meta-analyses were retrospective ones and originated from Asian countries (China and Korea, in particular). Examined overall population ranged from 3176 to 17,712 patients. If compared to LG, RG showed both operative advantages (operative time, estimated blood loss, number of retrieved lymph nodes) and perioperative ones (time to first flatus, time to restart oral intake, length of hospitalization, overall complications, Clavien-Dindo (CD) ≥ III complications, pancreatic complications), in the absence of clear differences of oncological outcomes. However, costs of robotic approach appear significant. Conclusions: It is impossible to make strong recommendations, due to the statistical weakness of the included studies. Further randomized, possibly multicenter trials are strongly recommended, if we want to have our results confirmed.
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Affiliation(s)
- Maurizio Zizzo
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.M.); (D.T.); (F.M.); (A.L.Z.); (A.G.)
- Correspondence: ; Tel.: +39-0522-296372; Fax: +39-0522-295779
| | - Magda Zanelli
- Pathology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (M.Z.); (A.P.)
| | - Francesca Sanguedolce
- Pathology Unit, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Foggia, 71122 Foggia, Italy;
| | - Federica Torricelli
- Laboratory of Translational Research, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Andrea Morini
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.M.); (D.T.); (F.M.); (A.L.Z.); (A.G.)
| | - David Tumiati
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.M.); (D.T.); (F.M.); (A.L.Z.); (A.G.)
| | - Federica Mereu
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.M.); (D.T.); (F.M.); (A.L.Z.); (A.G.)
| | - Antonia Lavinia Zuliani
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.M.); (D.T.); (F.M.); (A.L.Z.); (A.G.)
| | - Andrea Palicelli
- Pathology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (M.Z.); (A.P.)
| | - Stefano Ascani
- Hematology Unit, CREO, Azienda Ospedaliera di Perugia, University of Perugia, 06129 Perugia, Italy;
- Pathology Unit, Azienda Ospedaliera S. Maria di Terni, University of Perugia, 05100 Terni, Italy
| | - Alessandro Giunta
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.M.); (D.T.); (F.M.); (A.L.Z.); (A.G.)
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