Morbidity And Mortality Of Robotic And Laparoscopic Total Gastrectomy For Locally Advanced Gastric Cancer: A Prospective Cohort Study

BackgroundNowadays,gastric cancer(GC)is a high-incidence disease that seriously threatens human health.According to statistics,its incidence ranks sixth in the global cancer statistics,and its mortality ranks third.Due to the lack of specific signs in the early stage and economic-related factors,most patients are already in the advanced stage when diagnosed after symptoms appear.Although there are comprehensive treatments such as postoperative chemotherapy,neoadjuvant chemotherapy,radiotherapy and molecular targeted therapy,surgery is still the first choice for the treatment of gastric cancer.Since Kitano S first reported laparoscopic surgery for GC in 1994,laparoscopic gastrectomy(LG)has been widely carried out.At present,multi-center large-sample prospective randomized controlled studies have confirmed that LG for the gastric cancer patients with early stage is safe and reliable,and can achieve the same long-term performance.LG for gastric cancer in early stage has become the recommended treatment in guideline.Regarding advanced gastric cancer,the current relevant studies on LG for gastric cancer show that LG is safe and feasible,and the mid-and long-term efficacy is comparable to that of laparotomy.Robotic surgery began to be used in clinical practice in 2000.Due to its features of3 D imaging,elimination of tremors,and flexible operation,therefore,robotic surgery has gradually become the frontier and research hotspot in the field of minimally invasive surgery,thus entering a new era of minimally invasive surgery.The research on robotic versus laparoscopic surgery for gastric cancer has gradually increased,but most of them have focused on distal gastrectomy(DG).Nowadays,the incidence of upper gastric cancer and esophagogastric junction cancer is gradually increasing.Total gastrectomy(TG)as a standard surgical procedures for the treatment of upper and esophagogastric junction cancers are becoming increasingly important in clinical practice.Because TG is more difficult than DG,it is worth exploring whether robotic total gastrectomy(RTG)can provide patients with a good clinical performance.At present,there are few research reports on RTG,and that studies are all retrospective studies.The safety and efficacy of robotic versus laparoscopy in D2 radical total gastrectomy for locally advanced gastric cancer are not well understood.In this project,a metaanalysis of previous studies was conducted to preliminarily explore the clinical efficacy of robotic versus laparoscopic D2 radical total gastrectomy for locally advanced gastric cancer.We followly conducted a prospective study on robotics versus laparoscopic D2 radical gastrectomy for locally advanced gastric cancer,to provide evidence-based medicine for the widespread use of RTG for the treatment of locally advanced gastric cancer.Methods1.Comprehensive literature searches using search terms("laparoscopy","robotics","gastric cancer" and "gastrectomy")in databases(Pub Med,Web of Science,Embase,The Cochrane Library,LISTA(EBSCO)and the US Library of Congress).After screening and quality evaluation with the Newcastle-Ottawa Scale,the general characteristics of the included studies,the general conditions of the patients in the studies,the intraoperative and postoperative outcomes of the patients,and the postoperative complications were collected,and then a metaanalysis was performed using the Review Manager 5.3 software.2.This study was a prospective,single-center,noninferiority observation trial(registered on Clinical Trials.gov,NCT03500471).This study was approved by the Ethics Committee of the First Affiliated Hospital of Army Medical University(IRB number: KY201810).The subjects of the study were patients with locally advanced gastric adenocarcinoma(c T2-4aNx M0).After the sample size was estimated,75 patients in the robotic group and 75 patients in the laparoscopy group were enrolled.Robotic and laparoscopic total gastrectomy were performed in the two groups of patients,respectively.The incidence of surgical complications,mortality,and surgical outcomes,postoperative outcomes,cost and important laboratory test data.The survival data of the patients were collected for follow-up,and the mid-term efficacy of the two groups of patients was analyzed.Results1.After screening by inclusion and exclusion criteria,9 retrospective studies were included,all of which were eligible for quality evaluation.Meta-analysis showed that robotic operative time was longer(WMD=44.35,95%CI 28.40-60.30,P<0.001),But less operative blood loss(WMD=-14.04,95%CI-22.77 ～-5.32,P=0.002),shorter hospital stay(WMD=-0.78,95%CI-1.15～-0.42,P<0.001)and faster recovery of gastrointestinal function(WMD=-13.59,95% CI-19.60 to-7.59,P<0.001),last but no least,a lower incidence of postoperative complications(OR=0.73,95 % CI 0.55 to 0.97,P=0.03)(especially for minor postoperative complications OR=0.69,95% CI 0.48 to 0.99,P=0.04 and for intra-abdominal infection OR=0.31,95% CI0.15 to 0.63,P= 0.001).2.According to the inclusion and exclusion criteria,eligible patients were enrolled on March 26,2018,and the enrollment was completed on July 30,2021,during which a total of155 patients were recruited.Finally,after withdraw,69 patients in the robotic group and 73 patients in the laparoscopic group were included in the Per-Protocol analysis,and there was no significant difference in patient’s characteristic between the two groups.The overall postoperative morbidity rate was 21.74% in the RTG group and 28.77% in the LTG group with no significant difference(P = 0.44),RTG was associated with a lower incidence of pneumonia(4.35% vs.15.07%,P = 0.047).No mortality was observed in either group.There was no significant difference in the total operative time(284.48 vs.271.73 min,P=0.171),but RTG was associated with a lower estimated volume of blood loss(110 vs.150 ml,P<0.001)and more total retrieved lymph nodes(LNs)(41.36 vs 35.1,P = 0.019),more extraperigastric LNs(14.91 vs.12.19,P = 0.024)and more LNs in the suprapancreatic areas(14.68 vs.11.82,P =0.017).The levels of amylase after operation in robotic group were significantly lower than laparoscopic group.The levels of CRP,IL-6 and PCT in the robotic group were significantly lower than those in the laparoscopic group after operation.The levels of T-lymphocytes after the operation were significantly higher than those in the laparoscopic group.The risk factors for postoperative complications were analyzed,and comorbidy and operative time ≥300 minutes were independent risk factors for total gastrectomy.The 3-year survival rate and disease-free survival rate of the two groups were 76.12% vs 73.24% and 68.66% vs 70.72%,respectively,with no significant difference(P>0.05).Grouped according to TNM stage and serosa-invasive,there was no significant difference between the two groups of patients(P>0.05).Conclusions1.The postoperative complication of robotic radical gastrectomy is comparable to that of laparoscopic surgery,and robotic surgery has advantages in terms of pneumonia.The postoperative complications of radical total gastrectomy were related to the comorbidity before surgery and the total operation time ≥300 minutes.2.The operative time of robotic surgery is not significantly different from that of laparoscopic surgery,but the estimated volume of blood loss is less,the number of total retrieved lymph nodes is more,the surgical trauma is less,the postoperative recovery is faster,and the clinical effect is better.3.Robot radical total gastrectomy is a safe and feasible surgical procedure,which is worthy of further clinical application.