Comparative evaluation of robot-assisted, laparoscopic and open surgical interventions in the combined treatment of stomach cancer

Abstract

Introduction. Gastric cancer ranks fifth in incidence and fourth in mortality among all oncological diseases worldwide. According to recent clinical data, for stage cT2N0 and beyond, a combined approach using various schemes and regimens of anticancer drug therapy is recommended. Currently, indications for the use of minimally invasive techniques in the surgical treatment of locally advanced gastric cancer are not defined. Research objective. Comparative assessment of the immediate outcomes of robot-assisted, laparoscopic, and open surgical interventions in patients with gastric cancer of different localizations who underwent neoadjuvant polychemotherapy. Materials and methods. The study is based on a retrospective analysis of 81 medical histories of patients with locally advanced gastric cancer of different localizations operated on from 2018 to 2022 in the Department of Abdominal Oncology of City Hospital №40 in St. Petersburg. All patients underwent preoperative cycles of anticancer drug treatment within perioperative polychemotherapy schemes: FLOT – 64 (79%) patients, mFOLFOX6 – 9 (11.1%) patients, and FLOT+Тrastuzumab – 8 (9.9%) patients. Laparoscopic, traditional open, and robot-assisted surgical interventions were performed using the da Vinci surgical system. Results. Thirty-seven (45.7%) robot-assisted operations were performed, (22/27.2% – distal subtotal resections of the stomach (DSRS), 15/18.5% – gastrectomies (GE), 19 (23.5%) laparoscopic (11/13.6% – LDSRS, 8/9.9% – LGE), and 25 (30.9%) operations via laparotomy (9/11.1% – DSRS, 16/19.7% – GE). All patients underwent D2 and D2+ lymphadenectomy. Statistically significant differences were noted in groups for parameters such as operative intervention time, intraoperative blood loss, and length of hospital stay. Open surgical intervention group had significantly higher blood loss volume – median 275 (90.00; 300) ml (p<0.001) and postoperative hospital stay duration – median 10.00 (9.00–14.00) days (p=0.017). Operation time was significantly shorter compared to minimally invasive interventions – median 150.00 (97.50–210.00) minutes for distal resections and 150.00 (96.25–207.50) minutes for GE (p<0.005). There were no statistically significant differences in complication rates (p>0.05) and the number of removed lymph nodes (p=0.334). However, the percentage of early postoperative complications, including lethal outcomes, was higher in the open intervention group (n=4/16%) compared to laparoscopic (n=2/10.5%) and robot-assisted (n=2/5.4%). The overall frequency of postoperative complications IIIA–V according to the Clavien-Dindo classification was 9.9%. One (1.2%) case had a lethal outcome after open gastrectomy. Histological examination showed no tumor growth in the resection margins (R0) for all patients. Complete regression of the gastric tumor (CAP-0) was noted in one case (1.23%) after combined treatment. Nearly complete response to therapy was observed in 13 cases (16%) (CAP-1), partial response in 28 cases (34.6%) (CAP-2), and no response to neoadjuvant therapy in 39 cases (48.1%) (CAP-3). Conclusions. Minimally invasive surgical interventions in the combined treatment of locally advanced gastric cancer are feasible, safe, and oncologically justified. Robot-assisted surgery demonstrates advantages over open and laparoscopic surgery in parameters such as intraoperative blood loss, number of removed lymph nodes, activation and hospitalization periods.