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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).
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.

Data Sharing Statement: See Supplement 3.

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.

References
1.
Katai  H , Mizusawa  J , Katayama  H ,  et al.  Survival outcomes after laparoscopy-assisted distal gastrectomy versus open distal gastrectomy with nodal dissection for clinical stage IA or IB gastric cancer (JCOG0912): a multicentre, non-inferiority, phase 3 randomised controlled trial.   Lancet Gastroenterol Hepatol. 2020;5(2):142-151. doi:10.1016/S2468-1253(19)30332-2 PubMedGoogle ScholarCrossref
2.
Kim  W , Kim  HH , Han  SU ,  et al; Korean Laparo-endoscopic Gastrointestinal Surgery Study (KLASS) Group.  Decreased morbidity of laparoscopic distal gastrectomy compared with open distal gastrectomy for stage I gastric cancer: short-term outcomes from a multicenter randomized controlled trial (KLASS-01).   Ann Surg. 2016;263(1):28-35. doi:10.1097/SLA.0000000000001346 PubMedGoogle ScholarCrossref
3.
Kim  HH , Han  SU , Kim  MC ,  et al; Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS) Group.  Effect of laparoscopic distal gastrectomy vs open distal gastrectomy on long-term survival among patients with stage I gastric cancer: the KLASS-01 randomized clinical trial.   JAMA Oncol. 2019;5(4):506-513. doi:10.1001/jamaoncol.2018.6727 PubMedGoogle ScholarCrossref
4.
Hu  Y , Huang  C , Sun  Y ,  et al.  Morbidity and mortality of laparoscopic versus open D2 distal gastrectomy for advanced gastric cancer: a randomized controlled trial.   J Clin Oncol. 2016;34(12):1350-1357. doi:10.1200/JCO.2015.63.7215 PubMedGoogle ScholarCrossref
5.
Yu  J , Huang  C , Sun  Y ,  et al; Chinese Laparoscopic Gastrointestinal Surgery Study (CLASS) Group.  Effect of laparoscopic vs open distal gastrectomy on 3-year disease-free survival in patients with locally advanced gastric cancer: the CLASS-01 randomized clinical trial.   JAMA. 2019;321(20):1983-1992. doi:10.1001/jama.2019.5359 PubMedGoogle ScholarCrossref
6.
Ojima  T , Nakamura  M , Nakamori  M ,  et al.  Robotic radical lymphadenectomy without touching the pancreas during gastrectomy for gastric cancer.   Medicine (Baltimore). 2019;98(13):e15091. doi:10.1097/MD.0000000000015091 PubMedGoogle Scholar
7.
Jiang  X , Hiki  N , Nunobe  S ,  et al.  Postoperative pancreatic fistula and the risk factors of laparoscopy-assisted distal gastrectomy for early gastric cancer.   Ann Surg Oncol. 2012;19(1):115-121. doi:10.1245/s10434-011-1893-y PubMedGoogle ScholarCrossref
8.
Park  JM , Jin  SH , Lee  SR ,  et al.  Complications with laparoscopically assisted gastrectomy: multivariate analysis of 300 consecutive cases.   Surg Endosc. 2008;22(10):2133-2139. doi:10.1007/s00464-008-9962-4 PubMedGoogle ScholarCrossref
9.
Washio  M , Yamashita  K , Niihara  M , Hosoda  K , Hiki  N .  Postoperative pancreatic fistula after gastrectomy for gastric cancer.   Ann Gastroenterol Surg. 2020;4(6):618-627. doi:10.1002/ags3.12398 PubMedGoogle ScholarCrossref
10.
Yoshida  K , Honda  M , Kumamaru  H ,  et al.  Surgical outcomes of laparoscopic distal gastrectomy compared to open distal gastrectomy: a retrospective cohort study based on a nationwide registry database in Japan.   Ann Gastroenterol Surg. 2017;2(1):55-64. doi:10.1002/ags3.12054 PubMedGoogle ScholarCrossref
11.
Lee  S , Kim  JK , Kim  YN ,  et al.  Safety and feasibility of reduced-port robotic distal gastrectomy for gastric cancer: a phase I/II clinical trial.   Surg Endosc. 2017;31(10):4002-4009. doi:10.1007/s00464-017-5435-y PubMedGoogle ScholarCrossref
12.
Kim  YM , Son  T , Kim  HI , Noh  SH , Hyung  WJ .  Robotic D2 lymph node dissection during distal subtotal gastrectomy for gastric cancer: toward procedural standardization.   Ann Surg Oncol. 2016;23(8):2409-2410. doi:10.1245/s10434-016-5166-7 PubMedGoogle ScholarCrossref
13.
Ojima  T , Hayata  K , Yamaue  H .  Robotic complete lymphadenectomy at the splenic hilum during total gastrectomy for advanced gastric cancer (with video).   J Visc Surg. 2019;156(2):173-174. doi:10.1016/j.jviscsurg.2018.12.005 PubMedGoogle ScholarCrossref
14.
Lu  J , Zheng  CH , Xu  BB ,  et al.  Assessment of robotic versus laparoscopic distal gastrectomy for gastric cancer: a randomized controlled trial.   Ann Surg. 2021;273(5):858-867. doi:10.1097/SLA.0000000000004466 PubMedGoogle ScholarCrossref
15.
Dindo  D , Demartines  N , Clavien  PA .  Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.   Ann Surg. 2004;240(2):205-213. doi:10.1097/01.sla.0000133083.54934.ae PubMedGoogle ScholarCrossref
16.
Ojima  T , Nakamura  M , Nakamori  M ,  et al.  Robotic versus laparoscopic gastrectomy with lymph node dissection for gastric cancer: study protocol for a randomized controlled trial.   Trials. 2018;19(1):409. doi:10.1186/s13063-018-2810-5 PubMedGoogle ScholarCrossref
17.
Brierley  JD , Gospodarowicz  MK , Wittekind  C , eds.  TNM Classification of Malignant Tumours. 8th ed. Wiley-Blackwell; 2017.
18.
Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2018 (5th edition).  Gastric Cancer. 2021;24(1):1-21. doi:10.1007/s10120-020-01042-y
19.
Ojima  T , Nakamura  M , Hayata  K , Yamaue  H .  Robotic double tract reconstruction after proximal gastrectomy for gastric cancer.   Ann Surg Oncol. 2021;28(3):1445-1446. doi:10.1245/s10434-020-09015-2 PubMedGoogle ScholarCrossref
20.
Ojima  T , Nakamura  M , Hayata  K , Yamaue  H .  Laparoscopic Roux-en-Y reconstruction using conventional linear stapler in robotic total gastrectomy for gastric cancer.   Surg Oncol. 2020;33:9-10. doi:10.1016/j.suronc.2019.12.003 PubMedGoogle ScholarCrossref
21.
Ojima  T , Nakamura  M , Hayata  K ,  et al.  Laparoscopic Billroth I gastroduodenostomy in robotic distal gastrectomy for gastric cancers: fusion surgery.   Surg Laparosc Endosc Percutan Tech. 2019;29(6):520-523. doi:10.1097/SLE.0000000000000720 PubMedGoogle ScholarCrossref
22.
Ojima  T , Nakamura  M , Yamaue  H .  Full robotic Roux-en-Y reconstruction after gastrectomy for gastric cancer: a loop reconstruction technique.   Updates Surg. 2020;72(4):1279-1281. doi:10.1007/s13304-020-00889-1 PubMedGoogle ScholarCrossref
23.
Ojima  T , Nakamori  M , Nakamura  M , Hayata  K , Maruoka  S , Yamaue  H .  Fundoplication with 180-degree wrap during esophagogastrostomy after robotic proximal gastrectomy for early gastric cancer.   J Gastrointest Surg. 2018;22(8):1475-1476. doi:10.1007/s11605-018-3765-2 PubMedGoogle ScholarCrossref
24.
Ye  SP , Shi  J , Liu  DN ,  et al.  Robotic- versus laparoscopic-assisted distal gastrectomy with D2 lymphadenectomy for advanced gastric cancer based on propensity score matching: short-term outcomes at a high-capacity center.   Sci Rep. 2020;10(1):6502. doi:10.1038/s41598-020-63616-1 PubMedGoogle ScholarCrossref
25.
Liu  H , Kinoshita  T , Tonouchi  A , Kaito  A , Tokunaga  M .  What are the reasons for a longer operation time in robotic gastrectomy than in laparoscopic gastrectomy for stomach cancer?   Surg Endosc. 2019;33(1):192-198. doi:10.1007/s00464-018-6294-x PubMedGoogle ScholarCrossref
26.
Chen  K , Pan  Y , Zhang  B , Maher  H , Wang  XF , Cai  XJ .  Robotic versus laparoscopic gastrectomy for gastric cancer: a systematic review and updated meta-analysis.   BMC Surg. 2017;17(1):93. doi:10.1186/s12893-017-0290-2 PubMedGoogle ScholarCrossref
27.
Lu  J , Wang  W , Zheng  CH ,  et al.  Influence of total lymph node count on staging and survival after gastrectomy for gastric cancer: an analysis from a two-institution database in China.   Ann Surg Oncol. 2017;24(2):486-493. doi:10.1245/s10434-016-5494-7 PubMedGoogle ScholarCrossref
28.
Strong  VE , Russo  AE , Nakauchi  M ,  et al.  Robotic gastrectomy for gastric adenocarcinoma in the USA: insights and oncologic outcomes in 220 patients.   Ann Surg Oncol. 2021;28(2):742-750. doi:10.1245/s10434-020-08834-7 PubMedGoogle ScholarCrossref
29.
Guerrini  GP , Esposito  G , Magistri  P ,  et al.  Robotic versus laparoscopic gastrectomy for gastric cancer: the largest meta-analysis.   Int J Surg. 2020;82:210-228. doi:10.1016/j.ijsu.2020.07.053 PubMedGoogle ScholarCrossref
30.
Shin  HJ , Son  SY , Wang  B , Roh  CK , Hur  H , Han  SU .  Long-term comparison of robotic and laparoscopic gastrectomy for gastric cancer: a propensity score-weighted analysis of 2084 consecutive patients.   Ann Surg. 2020. doi:10.1097/SLA.0000000000003845 PubMedGoogle Scholar
31.
Kim  KM , An  JY , Kim  HI , Cheong  JH , Hyung  WJ , Noh  SH .  Major early complications following open, laparoscopic and robotic gastrectomy.   Br J Surg. 2012;99(12):1681-1687. doi:10.1002/bjs.8924 PubMedGoogle ScholarCrossref
32.
Suda  K , Nakauchi  M , Inaba  K , Ishida  Y , Uyama  I .  Robotic surgery for upper gastrointestinal cancer: current status and future perspectives.   Dig Endosc. 2016;28(7):701-713. doi:10.1111/den.12697 PubMedGoogle ScholarCrossref
33.
Seo  HS , Shim  JH , Jeon  HM , Park  CH , Song  KY .  Postoperative pancreatic fistula after robot distal gastrectomy.   J Surg Res. 2015;194(2):361-366. doi:10.1016/j.jss.2014.10.022 PubMedGoogle ScholarCrossref
34.
Ma  J , Li  X , Zhao  S , Zhang  R , Yang  D .  Robotic versus laparoscopic gastrectomy for gastric cancer: a systematic review and meta-analysis.   World J Surg Oncol. 2020;18(1):306. doi:10.1186/s12957-020-02080-7 PubMedGoogle ScholarCrossref
35.
Park  JY , Jo  MJ , Nam  BH ,  et al.  Surgical stress after robot-assisted distal gastrectomy and its economic implications.   Br J Surg. 2012;99(11):1554-1561. doi:10.1002/bjs.8887 PubMedGoogle ScholarCrossref
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