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

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

SUBMITTER: Ojima T

PROVIDER: S-EPMC6456026 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

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

Ojima Toshiyasu T Nakamura Masaki M Nakamori Mikihito M Hayata Keiji K Katsuda Masahiro M Maruoka Shimpei S Yamaue Hiroki H

Medicine 20190301 13

Laparoscopic lymph node dissection around the peripancreatic area for gastric cancer (GC) remains challenging because of drawbacks in laparoscopic surgery including the limited range of movement, amplification of hand tremors, and inconvenient surgical positioning. In some cases of laparoscopic gastrectomy (LG), therefore, postoperative pancreatic fistula (POPF) occurs. Robotic surgery, on the other hand, plays an essential role in ergonomics and offers advantages, such as motion scaling, less f ...[more]

PMID: 30921243

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Project description:ImportanceFluorescent imaging with indocyanine green can be used to visualize lymphatics. Peritumoral injection of indocyanine green may allow for visualization of every draining lymph node from a primary lesion on near-infrared imaging.ObjectivesTo evaluate the role of fluorescent lymphography using near-infrared imaging as an intraoperative tool for achieving complete lymph node dissection and compare the number of lymph nodes retrieved with the use of near-infrared imaging and the number of lymph nodes retrieved without the use of near-infrared imaging.Design, setting, and participantsThis prospective single-arm study was conducted among 40 patients who underwent robotic gastrectomy between August 30, 2013, and July 21, 2014, at a single-center, tertiary referral teaching hospital. After propensity score matching, the results of these 40 patients were compared with the results of 40 historical control patients who underwent robotic gastrectomy without indocyanine green injection between January 1, 2012, and August 31, 2013. Statistical analysis was performed from January 1, 2015, to July 31, 2016.InterventionsRobotic gastrectomy with systemic lymphadenectomy and retrieval of lymph nodes under near-infrared imaging after peritumoral injection of indocyanine green to the submucosal layer 1 day before surgery.Main outcomes and measuresThe primary outcome was the number of retrieved lymph nodes in each nodal station.ResultsAmong the 40 patients in the study (19 women and 21 men; mean [SD] age, 52.2 [11.7] years), no complications related to indocyanine green injection or near-infrared imaging were observed. On completion of the lymphadenectomy, the absence of fluorescent lymph nodes in the dissected area was confirmed. A mean (SD) total of 23.9 (9.0) fluorescent lymph nodes were recorded among a mean (SD) total of 48.9 (14.6) overall lymph nodes retrieved. The mean number of overall lymph nodes retrieved was larger in the near-infrared group than in the historical controls (48.9 vs 35.2; P < .001), with a significantly greater number of lymph nodes retrieved at stations 2, 6, 7, 8, and 9. In the near-infrared group, 5 patients exhibited lymph node metastases, and all metastatic lymph nodes were fluorescent.Conclusions and relevanceThis study's findings suggest that fluorescent lymphography may be useful intraoperatively for identifying and retrieving all necessary lymph nodes for a complete and thorough lymphadenectomy.

Project description: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.

Project description:BACKGROUND:To date, robotic surgery has been widely used worldwide. We conducted a systematic review and meta-analysis to evaluate short-term and long-term outcomes of robotic gastrectomy (RG) in gastric cancer patients to determine whether RG can replace laparoscopic gastrectomy (LG). METHODS:The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was applied to perform the study. Pubmed, Cochrane Library, WanFang, China National Knowledge Infrastructure (CNKI), and VIP databases were comprehensively searched for studies published before May 2020 that compared RG with LG. Next, two independent reviewers conducted literature screening and data extraction. The quality of the literature was assessed using the Newcastle-Ottawa Scale (NOS), and the data analyzed using the Review Manager 5.3 software. Random effects or fixed effects models were applied according to heterogeneity. RESULTS:A total of 19 studies including 7275 patients were included in the meta-analyses, of which 4598 patients were in the LG group and 2677 in the RG group. Compared with LG, RG was associated with longer operative time (WMD = -32.96, 95% CI -42.08 ~ -23.84, P < 0.001), less blood loss (WMD = 28.66, 95% CI 18.59 ~ 38.73, P < 0.001), and shorter time to first flatus (WMD = 0.16 95% CI 0.06 ~ 0.27, P = 0.003). There was no significant difference between RG and LG in terms of the hospital stay (WMD = 0.23, 95% CI -0.53 ~ 0.98, P = 0.560), overall postoperative complication (OR = 1.07, 95% CI 0.91 ~ 1.25, P = 0.430), mortality (OR = 0.67, 95% CI 0.24 ~ 1.90, P = 0.450), the number of harvested lymph nodes (WMD = -0.96, 95% CI -2.12 ~ 0.20, P = 0.100), proximal resection margin (WMD = -0.10, 95% CI -0.29 ~ 0.09, P = 0.300), and distal resection margin (WMD = 0.15, 95% CI -0.21 ~ 0.52, P = 0.410). No significant differences were found between the two treatments in overall survival (OS) (HR = 0.95, 95% CI 0.76 ~ 1.18, P = 0.640), recurrence-free survival (RFS) (HR = 0.91, 95% CI 0.69 ~ 1.21, P = 0.530), and recurrence rate (OR = 0.90, 95% CI 0.67 ~ 1.21, P = 0.500). CONCLUSIONS:The results of this study suggested that RG is as acceptable as LG in terms of short-term and long-term outcomes. RG can be performed as effectively and safely as LG. Moreover, more randomized controlled trials comparing the two techniques with rigorous study designs are still essential to evaluate the value of the robotic surgery for gastric cancer.

Project description:ImportanceRobotic gastrectomy (RG) for gastric cancer may be associated with decreased incidence of intra-abdominal infectious complications, including pancreatic fistula, leakage, and abscess. Prospective randomized clinical trials comparing laparoscopic gastrectomy (LG) and RG are thus required.ObjectiveTo compare the short-term surgical outcomes of RG with those of LG for patients with gastric cancer.Design, setting, and participantsIn this phase 3, prospective superiority randomized clinical trial of RG vs LG regarding reduction of complications, 241 patients with resectable gastric cancer (clinical stages I-III) were enrolled between April 1, 2018, and October 31, 2020.InterventionsLG vs RG.Main outcomes and measuresThe primary end point was the incidence of postoperative intra-abdominal infectious complications. Secondary end points were incidence of any complications, surgical results, postoperative courses, and oncologic outcomes. The modified intention-to-treat population excluded patients who had been randomized and met the postrandomization exclusion criteria. There was also a per-protocol population for analysis of postoperative complications.ResultsThis study enrolled 241 patients, with 236 patients in the modified intention-to-treat population (150 men [63.6%]; mean [SD] age, 70.8 [10.7] years). There was no significant difference in the incidence of intra-abdominal infectious complications (per-protocol population: 10 of 117 [8.5%] in the LG group vs 7 of 113 [6.2%] in the RG group). Of 241 patients, 122 were randomly assigned to the LG group, and 119 patients were randomly assigned to the RG group. Two of the 122 patients (1.6%) in the LG group converted from LG to open surgery, and 4 of 119 patients (3.4%) in the RG group converted from RG to open or laparoscopic surgery, with no significant difference. Finally, 117 patients in the LG group completed the procedure, and 113 in the RG group completed the procedure; these populations were defined as the per-protocol population. The overall incidence of postoperative complications of grade II or higher was significantly higher in the LG group (23 [19.7%]) than in the RG group (10 [8.8%]) (P = .02). Even in analysis limited to grade IIIa or higher, the complication rate was still significantly higher in the LG group (19 [16.2%]) than in the RG group (6 [5.3%]) (P = .01).Conclusions and relevanceThis study found no reduction of intra-abdominal infectious complications with RG compared with LG for gastric cancer.Trial registrationumin.ac.jp/ctr Identifier: UMIN000031536.

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

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

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