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Minimally Invasive Surgery

Short-term Outcomes of Robotic Gastrectomy vs Laparoscopic Gastrectomy for Patients With Gastric CancerA Randomized Clinical Trial

Educational Objective
To determine whether robotic gastrectomy (RG) for resectable gastric cancer reduces the incidence of intra-abdominal infectious complications compared with laparoscopic gastrectomy (LG).

1 Credit CME

JAMA Surgery

Published Online: September 1, 2021

Original Investigation

Article Information and Disclosures

Toshiyasu Ojima, MD, PhD¹;

Masaki Nakamura, MD, PhD¹;

Keiji Hayata, MD, PhD¹;

Junya Kitadani, MD, PhD¹;

Masahiro Katsuda, MD, PhD¹;

Akihiro Takeuchi, MD, PhD¹;

Shinta Tominaga, MD¹;

Tomoki Nakai, MD¹;

Mikihito Nakamori, MD, PhD¹;

Masaki Ohi, MD, PhD²;

Masato Kusunoki, MD, PhD²;

Hiroki Yamaue, MD, PhD¹

Author Affiliations

¹Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
²Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Mie, Japan

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Key Points

Question Does robotic gastrectomy for resectable gastric cancer reduce the incidence of intra-abdominal infectious complications compared with laparoscopic gastrectomy?

Findings In this randomized clinical trial of 241 patients with gastric cancer, the primary end point of reducing intra-abdominal infectious complications with robotic gastrectomy was not met. Secondary end point results showed good short-term surgical outcomes in both the laparoscopic gastrectomy group and the robotic gastrectomy group.

Meaning This study suggests that robotic gastrectomy for patients with gastric cancer is unable to reduce postoperative intra-abdominal complications.

Abstract

Importance Robotic 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.

Objective To compare the short-term surgical outcomes of RG with those of LG for patients with gastric cancer.

Design, Setting, and Participants In 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.

Interventions LG vs RG.

Main Outcomes and Measures The 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.

Results This 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 Relevance This study found no reduction of intra-abdominal infectious complications with RG compared with LG for gastric cancer.

Trial Registration umin.ac.jp/ctr Identifier: UMIN000031536

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Article Information

Accepted for Publication: May 5, 2021.

Published Online: September 1, 2021. doi:10.1001/jamasurg.2021.3182

Corresponding Author: Hiroki Yamaue, MD, PhD, Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama 641-8510, Japan (yamaue-h@wakayama-med.ac.jp).

Author Contributions: Dr Ojima had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ojima, Nakamura, Kusunoki, Yamaue.

Acquisition, analysis, or interpretation of data: Ojima, Nakamura, Hayata, Kitadani, Katsuda, Takeuchi, Tominaga, Nakai, Nakamori, Ohi.

Drafting of the manuscript: Ojima, Nakamura, Kitadani, Katsuda, Takeuchi, Tominaga, Nakai, Nakamori.

Critical revision of the manuscript for important intellectual content: Hayata, Ohi, Kusunoki, Yamaue.

Statistical analysis: Ojima, Nakamura, Katsuda.

Administrative, technical, or material support: Nakamura, Hayata, Kitadani, Katsuda, Takeuchi, Nakai, Nakamori, Ohi.

Supervision: Kusunoki, Yamaue.

Conflict of Interest Disclosures: None reported.

Additional Information: Benjamin Phillis, Clinical Study Support Center, Wakayama Medical University, provided proofreading and editing of this article. He was not compensated for his contribution.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.