Minimally invasive surgery for gastric cancer: A comparison between robotic, laparoscopic and open surgery

AIM To investigate the role of minimally invasive surgery for gastric cancer and determine surgical, clinical, and oncological outcomes.METHODS This is a propensity score-matched case-control study, comparing three treatment arms: robotic gastrectomy(RG), laparoscopic gastrectomy(LG), open gastrectomy(OG). Data collection started after sharing a specific study protocol. Data were recorded through a tailored and protected web-based system. Primary outcomes: harvested lymph nodes, estimated blood loss, hospital stay, complications rate. Among the secondary outcomes, there are: operative time, R0 resections, POD of mobilization, POD of starting liquid diet and soft solid diet. The analysis includes the evaluation of type and grade of postoperative complications. Detailed information of anastomotic leakages is also provided.RESULTS The present analysis was carried out of 1026 gastrectomies. To guarantee homogenous distribution of cases, patients in the RG, LG and OG groups were 1:1:2 matched using a propensity score analysis with a caliper = 0.2. The successful matching resulted in a total sample of 604 patients(RG = 151; LG = 151; OG = 302). The three groups showed no differences in all baseline patients characteristics, type of surgery(P = 0.42) and stage of the disease(P = 0.16). Intraoperative blood loss was significantly lower in the LG(95.93 ± 119.22) and RG(117.91 ± 68.11) groups compared to the OG(127.26 ± 79.50, P = 0.002). The mean number of retrieved lymph nodes was similar between the RG(27.78 ± 11.45), LG(24.58 ± 13.56) and OG(25.82 ± 12.07) approach. A benefit in favor of the minimally invasive approaches was found in the length of hospital stay(P < 0.0001). A similar complications rate was found(P = 0.13). The leakage rate was not different(P = 0.78) between groups.CONCLUSION Laparoscopic and robotic surgery can be safely performed and proposed as possible alternative to open surgery. The main highlighted benefit is a faster postoperative functional recovery.

Robotic liver surgery is the optimal approach as bridge to transplantation

The role of minimally invasive liver surgery as a bridge to transplantation is very promising but still underestimated. However, it should be noted that surgical approach for hepatocellular carcinomas(HCC) is not merely a technical or technological issue. Nowadays, the epidemiology of HCC is evolving due to the increasing role of non-alcoholic fatty-liver-disease, and the emerging concerns on direct-acting antivirals against hepatitis C virus in terms of HCC incidence. Therefore, a fully multidisciplinary study of the cirrhotic patient is currently more important than ever before, and the management of those patients should be reserved to tertiary referral hepatobiliary centers. In particular, minimally invasive approach to the liver showed several advantages compared to the classical open procedure, in terms of:(1) the small impact on abdominal wall;(2) the gentle manipulation on the liver;(3) the limited surgical trauma; and(4) the respect of venous shunts. Therefore, more direct indications should be outlined also in the Barcelona Clinic Liver Cancer model. We believe that treatment of HCC in cirrhotic patients should be reserved to tertiary referral hepatobiliary centers, that should offer patient-tailored approaches to the liver disease, in order to provide the best care for each case, according to the individual comorbidities, risk factors, and personal quality of life expectations.

Laparoscopic and robot-assisted gastrectomy for gastric cancer: Current considerations

Radical gastrectomy with an adequate lymph-adenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer(GC). A number of randomized controlled trials and meta-analysis provide phase Ⅲ evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage GC. While laparoscopic gastrectomy has become standard therapy for early-stage GC, especially in Asian countries such as Japan and South Korea, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Some intrinsic drawbacks of the conventional laparoscopic technique have prevented the worldwide spread of laparoscopic gastrectomyfor cancer and, despite technological advances in recent year, it remains a technically challenging procedure. The introduction of robotic surgery over the last ten years has implied a notable mutation of certain minimally invasive procedures, making it possible to overcome some limitations of the traditional laparoscopic technique. Robot-assisted gastric resection with D2 lymph node dissection has been shown to be safe and feasible in prospective and retrospective studies. However, to date there are no high quality comparative studies investigating the advantages of a robotic approach to GC over traditional laparoscopic and open gastrectomy. On the basis of the literature review here presented, robot-assisted surgery seems to fulfill oncologic criteria for D2 dissection and has a comparable oncologic outcome to traditional laparoscopic and open procedure. Robot-assisted gastrectomy was associated with the trend toward a shorter hospital stay with a comparable morbidity of conventional laparoscopic and open gastrectomy, but randomized clinical trials and longer follow-ups are needed to evaluate the possible influence of robot gastrectomy on GC patient survival.

Robot-assisted laparoscopic vs open gastrectomy for gastric cancer:Systematic review and meta-analysis

AIM To evaluate the potential effectiveness of robot-assisted gastrectomy(RAG) in comparison to open gastrectomy(OG) for gastric cancer patients.METHODS A comprehensive systematic literature search using PubM ed,EMBASE,and the Cochrane Library was carried out to identify studies comparing RAG and OG in gastric cancer.Participants of any age and sex were considered for inclusion in comparative studies of the two techniques independently from type of gastrectomy.A meta-analysis of short-term perioperative outcomes was performed to evaluate whether RAG is equivalent to OG.The primary outcome measures were set for estimated blood loss,operative time,conversion rate,morbidity,and hospital stay.Secondary among postoperative complications,wound infection,bleeding and anastomotic leakage were also analysed.RESULTS A total of 6 articles,5 retrospective and 1 randomized controlled study,involving 6123 patients overall,with 689(11.3%) cases submitted to RAG and 5434(88.7%) to OG,satisfied the eligibility criteria and were included in the meta-analysis.RAG was associated with longer operation time than OG(weighted mean difference 72.20 min;P < 0.001),but with reduction in blood loss and shorter hospital stay(weighted mean difference-166.83 mL and-1.97 d respectively;P < 0.001).No differences were found with respect to overall postoperative complications(P = 0.65),wound infection(P = 0.35),bleeding(P = 0.65),and anastomotic leakage(P = 0.06).The postoperative mortality rates were similar between the two groups.With respect to oncological outcomes,no statistical differences among the number of harvested lymph nodes were found(weighted mean difference-1.12;P = 0.10).CONCLUSION RAG seems to be a technically valid alternative to OG for performing radical gastrectomy in gastric cancer resulting in safe complications.

Pancreaticoduodenectomy in elderly patients:a special place for minimally invasive surgery?

To the Editor： We read with keen interest the recent paper by El Nakeeb et al, and the subsequent editorial published by Dudeja and Livingstone. Globally, the authors have correctly and timely portrayed the current role of pancreaticoduodenectomy in the elderly.

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. Robotassisted 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.

Minimally invasive liver resection: has the time come to consider robotics a valid assistance?

Minimally invasive liver resection (MILR) has been steadily increasing worldwide. Since its introduction in the early 1990s, initially adopted in cases of wedge and minor anatomical resection for benign hepatic lesions, MILR has been extended to major liver resection and for malignant hepatic lesions (1). Laparoscopic lateral sectionectomy has progressively become a standard operation (2).