Short-term Efficacy Of Robotic And Laparoscopic Total Gastrectomy For Gastric Cancer

BackgroundGastric cancer is a common malignant tumor of the digestive tract,making it the fifth most frequently diagnosed cancer and the third leading cause of cancer death.At present,the treatment of gastric cancer tends to be diversified and standardized,and the comprehensive treatment of gastric cancer has been greatly developed,including neoadjuvant therapy,chemotherapy,immunotherapy,gene therapy and other treatments.However,surgical treatment is still the mainstay of gastric cancer treatment.In recent years,the overall incidence of gastric cancer has declined worldwide,but the incidence of upper gastric cancer and esophagogastric junction cancer have gradually increased.Radical total gastrectomy with D2 lymphadenectomy is recommended for advanced upper gastric cancer and esophagogastric junction cancer.Since Kitano first reported laparoscopic gastric cancer surgery in 1994,laparoscopic surgery for gastric cancer has been widely applied worldwide.At present,laparoscopic gastrectomy for early gastric cancer has become a recommended treatment by the guideline.Laparoscopic-assisted total gastrectomy for gastric cancer was first reported by Azagra in 1999.The wide application of laparoscopic-assisted total gastrectomy is restricted by its highly technical difficulty,limited operating space and difficulty in digestive tract reconstruction.However,more and more studies have confirmed that laparoscopic-assisted total gastrectomy with D2 lymphadenectomy is safe and feasible,and the short-and long-term effects are comparable to those of open surgery.In 2002,Hashizume first reported robot-assisted gastrectomy for gastric cancer.Robot surgery for gastric cancer has been widely carried out worldwide since then.At present,related researches and meta-analysis at home and abroad confirm that robot-assisted gastrectomy can achieve similar short-term and long-term clinical efficacy as laparoscopy.Nevertheless,most studies of robotic surgery for gastric cancer focus on distal gastric cancer,few reports comparing robotic total gastrectomy with laparoscopic total gastrectomy for advanced gastric cancer.The incidence of postoperative complications is an important indicator for evaluating the safety of surgery.The higher incidence of complications after total gastrectomy than distal gastrectomy remains a major problem plagues surgeons.Clavien-Dindo classification system is currently used for assessing postoperative complications,which is widely used by surgeons in most parts of the world and in different specialties.Meanwhile,Slankamenac et al.proposed a new indicator,comprehensive complication index,based on the Clavien-Dindo classification system to comprehensively calculate the occurrence of all complications.ObjectiveThis study collected clinical data of patients who underwent robotic or laparoscopic total gastrectomy in the Department of General Surgery,Southwest Hospital,Army Medical University from March 2010 to March 2019,and compared the surgical status and short-term clinical efficacy of the two groups to explore the safety and feasibility of robotic and laparoscopic total gastrectomy.At the same time,it pays attention to the complications of robotic total gastrectomy,explores the risk factors of complications after robotic total gastrectomy,and provides evidence-based medical basis for robotic total gastrectomy comparing with laparoscopic total gastrectomy and further wishes to improve the clinical efficacy of robotic total gastrectomy.MethodsThe clinical data of patients undergoing robotic and laparoscopic total gastrectomy in the Department of General Surgery,Southwest Hospital,Army Medical University from March 2010 to March 2019 were collected.The cases were screened according to the inclusion criteria and exclusion criteria.General clinical data of patients,surg ical related information,postoperative recovery,postoperative complications etc.were collected.Retrospective analysis was used to compare the operation-related situation and clinical efficacy between the two groups.All data were analyzed by SPSS 22.0.The propensity score matching was conducted by MatchIt package of R software with a 1:1 matching.The matching variables included age,sex,BMI,ASA,T stage,N stage,TNM stage,tumor diameter,location,Borrmann classification,differentiation and comorbidity.The measurement data conforming to normal distribution are expressed as mean ± standard deviation(x(?)±s),and the counting data are expressed as number(%).The measurement data were analyzed by t test,the count data was tested by chi-square test or Fisher's exact method and the grade data was tested by Mann-Whitney U test.Logistic regression analysis was used to analyze the risk factors of complications.The variables with P<0.1 were included in the logistic regression analysis.The two groups were considered to have significant statistical differences when P<0.05.Results1.Comparison of short-term clinical outcome1.1 A total of 360 patients from March 2010 to December 2017 were collected for short-term outcome analysis,116 in robotic group and 244 in laparoscopic group.There were no significant differences in sex,age,BMI,ASA,tumor size,tumor location and TNM stage between the two groups before matching(P>0.05).However,significant differences were detected in T stage and differentiation between the two groups before matching(P<0.05).Whereas,the basic data of the two groups were well balanced and no signifi cant differences were detected after matching.What's more,the bias between the two groups was reduced after matching.1.2 The robotic group had longer operation time,more intraoperative bleeding,more retrieved lymph nodes and lymph nodes in the N2 station than the laparoscopic group before matching.While,the robotic group was still prior to the laparoscopic group in terms of operation time,intraoperative bleeding and the number of N2 station retrieved lymph nodes after matching.There were no significant differences in incision length,proximal length,distal length and postoperative hospital stay between the two groups(P>0.05).In terms of conversion,there were 6 cases in the robotic group and 23 cases in the laparoscopic group converted to open surgery(P=0.198);when comes to splenectomy rate,there were 2 cases in the robotic group and 1 case in the laparoscopic group(P=0.503).1.3 Postoperative complications were counted according to Clavien-Dindo classification.One patient died in the robotic group.There were 108 patients in the two groups encountered with postoperative complications before matching: 28 patients(24.1%)in the robotic group,70 patients(28.7%)in the laparoscopic group,no significant difference between the two groups(P>0.05).On the other hand,67 patients in the two groups encountered with postoperative complications after matching: 28 patients in the robotic group(24.1%)which was slightly less than the laparoscopic group with 39 patients(33.6%).However,no statistically significant difference was detected(P>0.05).Besides,there was no significant difference in the incidence of major complications(Clavien-Dindo??a)between the two groups before and after matching(5.2% vs.8.2%;P = 0.300),(5.2% vs.9.5%;P = 0.208).1.4 Subgroup analysis showed that robotic group had a trend of shorter operation time,less intraoperative bleeding and more retrieved lymph nodes compared with laparoscopic group when comparing EGJ tumors with non-EGJ tumors.In addition,patients with high BMI had longer operation time,fewer retrieved lymph nodes,more intraoperative bleeding and higher incidence of postoperative complications.2.Analysis of complications and risk factors after total gastrectomy2.1 A total of 173 patients were collected from March 2010 to Mar 2019,45 had postoperative complications,the total incidence of complications was 26%.Among 45 patients with postoperative complications,there were 5 cases of grade ?(2.9%),31 cases of grade ?(17.9%),2 cases of grade ?a(1.2%),3 cases of grade ?b(1.7%),1 case of grade ?a(0.6%),1 case of grade ?b(0.6%)and 2 cases of grade ?(1.2%).The incidence of severe complications was 5.2%(9/173).The incidence of CCI?25.2 was 11.0%(19/173).2.2 Univariate analysis of risk factors for postoperative complications showed that BMI,tumor diameter,intraoperative blood loss and operative time were factors associat ed with postoperative complications(P < 0.05).BMI,history of abdominal surgery,differentiation and intraoperative blood loss were the related factors affecting the occurrence of severity complications(P<0.05).Age,BMI and Charlson complications index were related factors affecting CCI?25.2(P<0.05).Multivariate analysis showed that tumor diameter ? 3cm and tumor located at the esophagogastric junction were independent risk factors for postoperative complications;BMI ? 25kg/m2 was an independent risk factor for postoperative severity complications;age ? 60 ys,BMI ?25kg/m2,history of abdominal surgery were independent risk factors for CCI?25.2.Conclusion1.Robotic-assisted total gastrectomy has an advantage over laparoscopic-assisted total gastrectomy in terms of intraoperative bleeding and lymph node dissection for advanced gastric cancer,and the incidence of complications of robotic surgery is slightly lower than that of laparoscopic surgery.2.Postoperative complications after robotic-assisted total gastrectomy for gastric cancer are mainly pulmonary-related grade ? complications.CCI can better predict the risk factors of severe complications than C-D classification.Age,BMI,tumors diameter,tumors location and history of abdominal surgery were independent risk factors for postoperative complications.3.Robotic-assisted total gastrectomy is safe and reliable compared with laparoscopic-assisted total gastrectomy for gastric cancer.The clinical effect of robotic gastrectomy is slightly better than laparoscopic gastrectomy.