Comparison of Short- and Long-term Efficacy of Robotic Versus Laparoscopic Gastrectomy in High-risk Patients With Gastric Cancer: a Nationwide, Multicentre Cohort Study
Trial Snapshot
- Phase
- Not Applicable
- Status
- Completed
- Sponsor
- Enrollment
- 534
- Primary Endpoint
- The main endpoints of this study were the 3-year cumulative incidence function (3y-CIF) of three-year mortality under a competing risk model, and 3-year disease-free survival (3y-DFS) with secondary outcomes, including three-year recurrence patterns.
Study Overview
Brief Summary
Since 2007, robotic gastrectomy (RG) has been considered an option for minimally invasive surgery (MIS)1. In recent years, several randomised trials and retrospective studies have compared short-term efficacy and oncological outcomes between RG and laparoscopic gastrectomy (LG)2-5. Compared with traditional laparoscopic gastric surgery, RG may yield better short-term and comparable long-term outcomes4-6.
According to previous studies7, 8, American Society of Anesthesiologists (ASA) grade ≥3, body mass index (BMI) ≥ 30 kg/m2, age ≥80 years, and clinical T4 stage are considered to be sensitive indicators for assessing surgical risk among patients with cancer. Patients with any of these factors were defined as high risk patients who constitute a special group. Previous research has shown that obesity, advanced age, comorbid conditions, and tumour cT stage are factors associated with mortality and complication rates in MIS for gastrointestinal malignancies6,7. Therefore, it is crucial to explore the impact of high-risk factors on prognosis. Many elderly patients have comorbidities with a high incidence of cardiopulmonary disease(s)8-10. Moreover, patients with poor baseline conditions often struggle to tolerate major surgery, and their comorbid state and ASA score are high-risk factors that affect postoperative complications and prognosis11-14. High BMI, especially among obese patients in whom excessive abdominal fat obscures anatomical regions, limits the flexibility of laparoscopic instruments, hinders complex perivascular lymph node dissection, and increases the difficulty of D2 lymphadenectomy, may increase postoperative complications15-17. Advanced-stage tumours, particularly those at the cT4 stage, present with more enlarged metastatic lymph nodes, making the exposure of vessels and dissection more challenging6,7. All of these factors are considered to be high-risk factors for surgical procedures. With the increasing prevalence of aging populations and obesity18-20, more high-risk patients with resectable gastric cancer (GC) are undergoing MIS.
To further explore this increasing concern about clinical practice, our study is the first to compare the short- and long-term outcomes of RG and LG in a high-risk gastric cancer population, with the aim of providing high-level, evidence-based medicine for the widespread application of RG in this population. To the best of our knowledge, this is the first multicentre, large-sample study to compare the advantages of RG and LG in a high-risk GC population.
Detailed Description
A retrospective collection of clinical, pathological, and follow-up data was conducted on 1 103 patients who underwent radical RG and 2 515 who underwent radical LG at eight high-volume tertiary hospitals in China between August 2016 and June 2019.
The inclusion criteria were as follows: postoperative pathological staging of T1-4aN0-3bM0 gastric adenocarcinoma; and radical gastrectomy with gastric lymph node dissection. Exclusion criteria included: residual gastric cancer (n=52); concurrent/past malignancies (n = 58); loss to follow-up (n = 123); previous indocyanine green-guided lymph node dissection (n = 125); undergoing neoadjuvant chemotherapy (n = 144 [RG group, n = 7]; LG group, n = 137]); and patients without high-risk factors (n = 1617). These inclusion criteria identified 2 001 patients for baseline analysis. The study was approved by the institutional review board of each participating centre.
Propensity score matching and sample size Propensity score matching (PSM) was used to adjust for the different baseline characteristics between the RG and LG groups. A 1:1 ratio PSM was performed using the nearest neighbour matching method with a caliper of 0.2. Fourteen factors, including age, ASA class, previous abdominal surgery, tumour size, tumour location, resection extent, extent of lymphadenectomy, histology, cT, cN, pT, pN, and adjuvant chemotherapy were included.Ultimately, data from 1 068 patients were included in the analysis (eFig 1). The balance of matching between the two groups was assessed using the standardised mean difference (SMD), with a value < 0.1 considered to be acceptable.
Surgical quality control and perioperative management All surgeons participating in this study were from high-capacity tertiary referral centres and surpassed the learning curve associated with LG. The da Vinci robotic system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) was used for all RGs, with surgeons receiving standardised RG training and operational certification.
Surgical intervention was initiated after obtaining informed consent from all patients, which included the additional costs of robotic surgery, a comprehensive explanation of surgical risks, and potential alternative treatments, thus facilitating informed surgical approach choices (i.e., LG or RG) within the participating institutions. Adherence to the "Japanese Gastric Cancer Treatment Guidelines" was maintained for determining the extent of gastrectomy and lymphadenectomy.21,22 RG operating procedures are similar to LG in terms of trocar placement, surgical phases, and anastomosis techniques, with detailed procedural delineations available elsewhere.2,23 Postoperative morbidity and mortality were assessed within a 30-day framework using the Clavien-Dindo classification system24. Complications were categorised as surgical and systemic, and were defined based on previous descriptions25, with intraoperative blood loss ≥400 ml defined as massive haemorrhage in accordance with the existing literature26.
Study Design
- Study Type
- Observational
- Observational Model
- Cohort
- Time Perspective
- Retrospective
Eligibility Criteria
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •postoperative pathological staging of T1-4aN0-3bM0 gastric adenocarcinoma; and radical gastrectomy with gastric lymph node dissection. According to previous studies7, 8, American Society of Anesthesiologists (ASA) grade ≥3, body mass index (BMI) ≥ 30 kg/m2, age ≥80 years, and clinical T4 stage are considered to be sensitive indicators for assessing surgical risk among patients with cancer
Exclusion Criteria
- •Exclusion criteria included: residual gastric cancer ; concurrent/past malignancies ; loss to follow-up ; previous indocyanine green-guided lymph node dissection ; undergoing neoadjuvant chemotherapy; and patients without high-risk factors . These inclusion criteria identified 2 001 patients for baseline analysis.
Outcomes
Primary Outcomes
The main endpoints of this study were the 3-year cumulative incidence function (3y-CIF) of three-year mortality under a competing risk model, and 3-year disease-free survival (3y-DFS) with secondary outcomes, including three-year recurrence patterns.
Time Frame: 3 years
DFS was estimated using the Kaplan-Meier method, and comparisons were performed using the log-rank test. Given the high-risk population in this study, in which non-tumour-related deaths may occur, a competing risk model was used to analyse prognosis more accurately by excluding non-tumor-related deaths. CIFs were estimated using the competing risk model, and comparisons were performed using the Fine-Gray test. For recurrence, all-cause mortality was considered a competing event, and cumulative recurrence rates were calculated using a competing risk model.
Secondary Outcomes
No secondary outcomes reported
Investigators
Chang-Ming Huang, Prof.
Comparison of short- and long-term efficacy of robotic versus laparoscopic gastrectomy in high-risk patients with gastric cancer: a nationwide, multicentre cohort study
Fujian Medical University