| BackgroundGastric cancer is still regarded as the fourth most frequently occurring malignancy and the second cause of cancer-related death worldwide. And China has a high incidence of gastric cancer, and about 260,000 people die from the disease each year, with the mortality following lung cancer and liver cancer. Gastric cancer is a serious threat to the health of the people in the world, especially in China. Surgical resection still prevails as the only curative treatment for gastric cancer. Radical gastrectomy for gastric cancer has made significant progress in recent two decades. Not only has the radical resection rate and survival rate significantly improved, but also the application of minimally invasive surgery is widely accepted, making the patients get faster and better recovery. Among them, laparoscopic radical gastrectomy and robotic radical gastrectomy can be not only used in early gastric cancer, but also used in advanced gastric cancer, with a wide operation indication. In contrast with the conventional open radical gastrectomy, laparoscopic and robotic radical gastrectomy have a lot of advantages including less invasiveness and postoperative pain, fewer postoperative complications, faster recovery, shorter hospital stays. At present, the short-term and long-term curative efficacies of laparoscopic radical gastrectomy have been gradually recognized. Howerver, Da Vinci robotic radical gastrectomy for gastric cancer is still in the exploratory stage, and there are few related researches. Its safety and feasibility, the short and long-term efficacy still need further studies.In terms of the radical gastrectomy for gastric cancer, the whole process includes total or partial gastrectomy, perigastric lymph node dissection and digestive tract reconstruction. The operation is complex, and the invasive trauma is large, resulting in a higher complication rate. Different clinical trials reported postoperative complication rates ranging from 12–46% in the open radical gastrectomy and around 8% in the laparoscopic radical gastrectomy for gastric cancer. The postoperative complications of robotic gastrectomy are rarely reported.Only few researches reported that the incidence rate was similar to that of laparoscopic radical gastrectomy for gastric cancer, but the number of cases was so small, with a lack of evidence on large number of cases. Although the incidence of postoperative complications is still the most frequent indicator for measuring the operative quality, there is still no consensus on the definition and classification of postoperative complications, resulting in a difficult evaluation of surgical procedures. Therefore, a standardized classification system for postoperative complications which should be simple, reproducible, flexible, and applicable irrespective of the cultural background is necessary in the surgical field. To meet these needs, Dindo et al proposed the Clavien-Dindo classification system for complications in 2004. It has been gradually recognized and applied in many fields including cardiothoracic surgery, urologic surgery and general surgery, with its rationality being gradually confirmed. The robotic surgery is regarded as a new technology and its postoperative complications received extensive attention. But a standardized evaluation system on the occurrence and severity of complications after robotic gastrectomy is essential. So it is necessary to conduct a study about the postoperative complications following robotic radical gastrectomy based on Clavien-Dindo classification system for studing the occurrence rule and analysis of related factors, aiming to prevent and control the robotic postoperative complications. In addition, the complications following radical gastrectomy for gastric cancer are affected by many factors, including the patient’s condition, surgical factors and perioperative treatment etc. It is also necessary to assess the risk factors of complications after radical gastrectomy to reduce and prevent its occurrence.PurposeThis study was designed to compare surgical performance, short-term efficacy after robotic, laparoscopic, or open gastrectomy by analyzing the clinical data of patients who underwent robotic, laparoscopic, or open gastrectomy for gastric caner during the same period in Department of General Surgery, Southwest Hospital, Third Military Medical University. On the other hand, the postoperative complications following robotic, conventional laparoscopic and open surgery were evaluated and compared according to the Clavien-Dindo classification system. And risk factors for complications following radical gastrectomy were assessed, in order to provide further proofs for the safety and feasibility of Da Vinci robotic surgery as well as the prevention and controlment of the postoperative complications after radical gastrectomy for gastric cancer.MethodsThis study comprised all patients who underwent radical gastrectomy for gastric cancer from Department of General Surgery, Southwest Hospital, Third Military Medical University) during the period from January 2010 to December 2014. Remnant gastrectomy, simple laparotomy or gastrojejunostomy and emergency surgery were excluded. Patient demographics, surgical performance, and short-term clinical outcomes were collected and examined. Using case-control methods, we compared surgical performance and short-term clinical outcomes among da Vinci robotic surgery group, laparoscopic group and open group to evaluate the three surgical techniques. On the other hand, the postoperative complications following robotic, conventional laparoscopic and open surgery were evaluated and compared based on the Clavien-Dindo classification system. And risk factors for complications following radical gastrectomy were assessed by multivariate logistic regression method, thus providing further evidence for the safety and feasibility of Da Vinci robotic surgery as well as the prevention and controlment of the postoperative complications after radical gastrectomy for gastric cancer. In addition, we used the cumulative summation analysis to evaluate the improvement of robotic radical gastrectomy on two skilled laparoscopic surgeons at our center, in order to understand the da Vinci robotic learning curve and impact on the occurrence of complications.All statistical calculations were performed with statistical software SPSS 13.0 for Windows(SPSS, Inc., Chicago, IL). Data were expressed as the mean ± standard deviation.Part of classification and comparison of complications following robotic, laparoscopic and open radical gastrectomy: Continuous variables were compared by the Kruskal-Wallis test or one-way ANOVA test with post hoc multiple comparison by LSD procedure after normality tests was used for continuous variables and the chi-square test or Fisher’s exact test was used for categorical variables. P < 0.05 was considered to be statistically significant.Part of the relationship between the robotic learning curve and the occurrence of complications: For intergroup comparison the Mann-Whitney test or independent sample t-test was used for continuous variable after normality tests and the chi-square test was used for categorical variables. For interphase comparisons, the Kruskal-Wallis test or one-way ANOVA test with post hoc multiple comparison by LSD procedure after normality tests was used for continuous variables and the chi-square test was used for categorical variables. P < 0.05 was considered to be statistically significant.Part of classification and risk factors for complications following radical gastrectomy: Univariate analysis was performed with the chi-square test or Fisher’s exact test, Variables with p<0.10 in the univariate analysis were considered in a multivariate analysis. A binary logistic regression model was used for multivariate analysis to evaluate the risk factors that might affect postoperative complications and P < 0.05 was considered statistically significant while the variable was identified as an independent predictor.ResultsA total of 1327 cases were enrolled in the study, including 304 robotic radical gastrectomy, 705 laparoscopic radical gastrectomy, and 318 open radical gastrectomy. There are no significant differences between the three groups in the basic clinical characteristics, such as age, sex, BMI, previous surgery and TNM stage. Significant differences were found in operation time, the number of retrieved lymph nodes, intraoperative blood loss, days of first flatus, days of eating liquid diet and length of postoperative hospital stay. In terms of operation time, robotic surgery took the longest time while open surgery took the shortest time(235.9±56.2 min vs 226.5±58.6 min vs 213.1±53.2 min, p<0.001). In terms of retrieved lymph nodes, robotic gastrectomy could harvest more lymph nodes than laparoscopic or open gastrectomy, but no difference was found between laparoscopic group and open group(34.1±12.5 vs 32.5±10.1 vs 31.6±11.0, p=0.012). In terms of intraoperative blood loss, robotic group had the least blood loss, whereas open group had the most blood loss(119.2±51.7 ml vs 143.0±88.7 ml vs 250.1±175.4 ml, p<0.001). In terms of postoperative recovery index, such as days of first flatus, days of eating liquid diet and length of postoperative hospital stay, open group require a longer time than robotic or laparoscopic group, but there are no significant differences between robotic group and laparoscopic group.According to the standard of Clavien-Dindo classification system, the overall incidences of complications following robotic, laparoscopic and open gastrectomy were 10.9%, 12.6%, 18.6%, respectively. The majority of complications were grade I and II complications, whereas the incidences of severe complication classified as grade III or above were very low, with 2.3%, 2.6% and 3.1% in robotic, laparoscopic and open group, respectively. For the comparison of complications, robotic gastrectomy and laparoscopic gastrectmoy didn’t differ significantly from each other in any grade complication, whereas open gastrectomy had a higher incidence than the other groups in grade II complication and overall complications.Age of 65 years old or more(odds ratio, 1.797; 95 % CI, 1.277-2.529; p = 0.001), ASA score of 3 or more(odds ratio, 1.861; 95 % CI, 1.208-2.867; p = 0.005), multiorgan resection(odds ratio, 2.053; 95 % CI, 1.110-3.796; p = 0.022) and open surgery(odds ratio, 1.533; 95 % CI, 1.083-2.169; p = 0.016) were identified as independent risk factors for a higher rate of overall complications after radical gastrectomy; Age of 65 years old or more(odds ratio, 3.876; 95 % CI, 1.953-7.693; p<0.001), ASA score of 3 or more(odds ratio, 4.751; 95 % CI, 2.325-9.707; p<0.001), multiorgan resection(odds ratio, 4.796; 95 % CI, 1.906-12.071; p = 0.001), and open surgery(odds ratio, 2.054; 95 % CI, 1.020-4.135; p = 0.044) were identified as independent risk factors for a higher rate of severe postoperative complications after radical gastrectomy.ConclusionsIn contrast with open surgery, robotic or laparoscopic surgery has advantages including less invasiveness, quicker recovery. Robotic gastrectomy is a feasible and safe surgical procedure and can bring similar or even better surgical outcomes in comparison with laparoscopic gastrectomy. The Clavien?Dindo system is simple and feasible in the evaluation of complications following radical gastrectomy and should be promoted. It has a broad applicability. Da Vinci robotic and laparoscopic surgery, which were both regarded as minimally invasive surgery, are better than open surgery in terms of postoperative complications, bringing a faster recovery and higher quality of life for patients after surgery.The CUSUM method is a useful and objective tool for evaluation of practical skills for surgeons during the learning phase of robotic surgery training. The data suggest that after a learning curve phase of 12 to 14 cases, the laparoscopic surgeons can be more and more skillful. The surgeons become skilled in the new technology after about 30 cases, achieving a higher level of competence to perform operation for more complex patients. Moreover, the learning curve of robotic radical gastrectomy doesn’t increase the occurrence of postoperative complications. So the popularity of robotic surgical system won’t reduce because of its difficulty to learn or postoperative complicatons, we believe that there will be more robotic surgeons in the near future.Factors associated with complications following radical gastrectomy include age, ASA score, multiorgan resection and surgical method. Besides we try our best to get a detailed understanding of the patients’ history and carry out a physical examination, we still need a detailed examination to know the function of each organ in patients. On the basis of a full assessment for the patient’s general condition, we choose a reasonable surgical scheme to minimize the presence of risk factors, in order to reduce the incidence of postoperative complications and achieve the best therapeutic effect. |
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