| BackgroundGastric cancer is a common malignant tumor of the digestive tract and is one of the diseases that seriously threaten human life and health.The morbidity of gastric cancer varies from region to region and it is significantly higher in East Asian countries,such as Japan,Korea,and China.In China,according to registration data of the National Cancer Center in 2015,the morbidity of gastric cancer ranks the second among malignant tumors,and the mortality ranks the third among malignant tumors.Although the application of neoadjuvant chemotherapy,postoperative adjuvant chemotherapy,targeted therapy and radiotherapy has further expanded and strengthened the treatment strategy of gastric cancer,surgical resection remains the core of the treatment strategy of gastric cancer.In recent decades,the overall incidence of gastric cancer has been decreasing globally,while the incidence of upper gastric cancer has been increasing.As one of the commonly surgical methods in the treatment of upper gastric cancer,total gastrectomy has been increasingly adopted in clinical practice.Since laparoscopic gastrectomy was reported firstly by Kitano in 1994,it has gradually been widely adopted in clinical practice all over the world,and has been recognized as a safe and minimally invasive surgical method for gastric cancer.More and more clinical studies have reported the clinical efficacy of laparoscopic gastrectomy,showing that,compared with traditional open surgery,it has the advantages of less trauma,less intraoperative bleeding,less pain,faster recovery and lower complication rate.At present,the laparoscopic distal gastrectomy has been recommended for early gastric cancer by the treatment guidelines of gastric cancer.However,although the safety and technical feasibility of laparoscopic total gastrectomy has been verified by a lot of studies,it is restricted for wide application due to the drawback of laparoscopic instruments,and high technical difficulty in dissection of lymph node and reconstruction of digestive tract.In 2000,the Da Vinci Surgical System began to be applied for surgical operation.It provides a clearer three-dimensional vision and highly flexible mechanical wrist,and eliminated physiological trembling,which break through the technical limitations of the laparoscopic system,making the surgical operation more flexible and accurate.In 2002,Hashizume and his colleagues reported robot-assisted gastrectomy firstly.Then the application of robotic gastrectomy has been increasing year by year.Currently,numerous studies have confirmed that robotic gastrectomy is able to acquire good clinical efficacy,but these studies mostly focus on distal gastrectomy.However,there are few studies have discussed the clinical efficacy of robotic total gastrectomy,and those reports mainly focus on the short-term efficacy,while evidence of long-term efficacy is scant.Therefore,to provide more evidence supporting its application,this study discussed and evaluated the clinical efficacy of robotic total gastrectomy.ObjectiveTo provide evidence-based medical evidence for the extensive application of robotic radical total gastrectomy for gastric cancer,a meta-analysis comparing the clinical efficacy of robotic radical total gastrectomy with laparoscopic radical total gastrectomy was performed to discuss safety and feasibility of robotic radical total gastrectomy for gastric cancer.Meanwhile,the long-term efficacy and prognostic factors of robotic radical total gastrectomy for gastric cancer were retrospectively analyzed.MethodsPart ? Systemic search were performed in PubMed,Web of Science,Embase,and Cochrane library database up to August,2019.Terms,such as“gastric cancer”,“stomach cancer”,“gastrectomy”,“laparoscopic”and“robotic”were combined to explore all potential articles containing comparison of robotic total gastrectomy(RTG)with laparoscopic total gastrectomy(LTG).Two researchers completed the screening and quality evaluation of literatures,and extracted data about clinical efficacy of robotic total gastrectomy compared with laparoscopic total gastrectomy independently.Meta-analysis was conducted with RevMan software version 5.3.Continuous variables were expressed by mean difference(MD)and 95%confidence interval(95%CI),while dichotomous variables were expressed by odds ratio(OR)and 95%confidence interval(95%CI).The heterogeneity of included literatures was evaluated with I~2 value.Funnel plots were used to assess potential publication bias of included literatures.Part ? Clinicopathological data of gastric cancer patients who underwent robotic radical total gastrectomy admitted in the Department of General Surgery,the First Affiliated Hospital of Army Medical University,from March 2010 to November 2018,were analyzed retrospectively.General clinicopathological data as well as information of postoperative survival of patients were collected to assess the long-term efficacy of robotic radical total gastrectomy and explore the prognosis factors.The measurement data were expressed in the form of mean±standard deviation,and the count data were represented by the number of cases and percentage.Statistical analysis was conducted with SPSS 25.0 software.The x-tile software was applied to calculate the grouping cutoff of the number of lymph nodes dissected at stations 2.Overall survival rate and disease-free survival rate were calculated by Kaplan-Meier method.Cox regression analysis was used to analyze the prognostic factors.Multivariate analysis was applied to analyze independent prognostic factors from factors with P<0.1 in univariate analysis.P<0.05 indicated statistically significant differences.ResultsPart ? This study included eleven non-randomized studies that compared RTG with LTG for gastric cancer with a total of 1289 patients.The meta-analysis indicated that RTG led to less blood loss and earlier first flatus,and retrieved more lymph nodes,whereas it had longer operative time.Regarding the length of proximal resection margin,hospital stays and postoperative overall complications rate,no significant difference was found between RTG and LTG.Remarkably,the meta-analysis of postoperative serious complication(Clavien-Dindo classification??a)showed slightly lower morbidity after RTG.Part ? There were 166 patients in this study.Pathological stages were 19 cases(11.4%)for stage?,43 cases(25.9%)for stage??104 cases(62.7%)for stage?.Total number of lymphnodes dissected was 34.8±17.5 and total number of lymph nodes dissected at stations 2 was10.1±6.7.The median follow-up time was 25 months,ranged from 2 to 109 months.By the end of follow-up,a total of 68 patients died,among which 52 patients died for tumor-related diseases and 16 died for other causes.During the period of follow-up,8 patients were lost.There were 55patients with recurrence,including 17 cases with peritoneal metastasis(10.2%),15 cases with hematogenous metastasis(9.0%),6 with for local recurrence(3.6%),3 cases with distant lymph node metastasis(1.8%),10 cases with mixed metastasis(6.0%),and 4 cases(2.4%)with unknown mode.The 3-year overall survival rates and 5-year overall survival rates were 55.8%and 46.2%,respectively;The 3-year disease-free survival rates and 5-year disease-free survival rates were 53.4%and 45.4%,respectively.Univariate analysis and Multivariate analysis showed that TNM stage and the total number of lymph node dissection at station 2 were independent prognostic factors for overall survival rate.Conclusion1.Compared with laparoscopic total gastrectomy for gastric cancer,robotic total gastrectomy for gastric cancer has longer operative time,less intraoperative blood loss,more lymph node dissection,and a lower incidence of postoperative serious complications.The postoperative overall complication rate was similar between two groups.Therefore,robotic total gastrectomy for gastric cancer is safe and feasible.2.The long-term efficacy of robotic radical total gastrectomy is satisfactory.The relevant factors affecting the postoperative overall survival rate include postoperative TNM stage,total number of lymph nodes dissected,and the number of lymph nodes dissected at 2 stations.The TNM stage and the number of lymph nodes dissected at 2 stations were the independent prognostic factors for postoperative overall survival rate.3.This study provides a certainty theoretical basis for the clinical application of robotic total gastrectomy for gastric cancer... |
PDF Full Text Request