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Stomach Cancer: A Meta-Analysis Of Robotic Surgery Complications

Stomach Cancer: A Meta-Analysis Of Robotic Surgery Complications

Gastric or stomach cancer prevalence varies significantly around the world, with higher rates in Asia, Africa, South America, and Eastern Europe. However, in the United States, stomach cancer is a growing concern due to its increased occurrence in the elderly population and its poor prognosis. In European countries, the prevalence of stomach cancer differs from that in the United States. Recent European studies have suggested that microinvasive surgery (MIS) outcomes are comparable to those in Asian populations.

Stomach cancer ranks as the fifth most common cancer globally and is the third leading cause of cancer-related deaths. MIS has gained international recognition as a treatment option in recent years. Traditional surgical approaches for stomach cancer have seen limited evolution since Billroth’s pioneering resection in 1881. Large-scale studies have demonstrated the effectiveness and safety of MIS, showing improved short-term results and comparable long-term cancer outcomes compared to open surgery.

However, despite its advantages, MIS has not been widely adopted due to its technical complexity, limiting surgical flexibility and lymph node dissection. To address these challenges, robotics has been introduced into the surgical field. Numerous studies indicate that robots can enhance the performance of complex procedures. Nevertheless, there is a lack of direct comparisons between robotics and open procedures. This research aims to explore the potential benefits of robotic surgery in treating stomach cancer, particularly regarding postoperative complications, and to provide insights into the rationale for using robots in this context.

The Study

The study aimed to investigate the effectiveness of robotic surgical treatment in reducing postoperative wound infections in patients with gastric carcinoma. Additionally, it sought to identify other advantages of robotic procedures over traditional open surgeries in the context of postoperative stomach cancer care.

Numerous studies have investigated the impact of robotic surgeries on postoperative complications in patients with stomach cancer. However, there is a notable scarcity of reports addressing the specific effects of robotic operations on postoperative complications in this patient population. Consequently, recognizing the significance of this research, a team conducted a comprehensive meta-analysis to assess the influence of robotic surgeries on post-surgical complications.


Search Strategy

Starting from its initial release in June 2023, the research team conducted searches across four widely used databases: PubMed, Embase, Cochrane Library, and the Web of Science. Two researchers performed a thorough search. It’s worth noting that this system did not encompass certain types of documents, such as expert opinions, meeting reports, articles, research and committee reports, and ongoing research.

Inclusion and Exclusion Criteria

The classification criteria were established based on Population, Intervention, Comparison, Outcome, and Study Design (PICOS) principles. The inclusion criteria encompassed patients undergoing surgical treatment for stomach cancer, comparative research between robotic and open surgeries, assessment of complications at the surgical site, and cohort study designs. On the other hand, the exclusion criteria included clinical trials without surgical interventions for stomach cancer patients, a lack of clinical trials comparing robot-assisted procedures to open surgery for stomach cancer patients, and the exclusion of publications in the form of abstracts, meetings, case reports, reviews, duplicates, and incomplete studies.

Study Selection

Data extracted from the databases were managed using EndNote. All selected trials underwent individual screening by two investigators in line with the study’s exclusion criteria. Duplicate records were initially eliminated by assessing titles, abstracts, and full-text content. Later, manual checks were conducted to ensure data integrity. In cases of disagreements during the screening process, a third independent investigator was consulted to resolve any discrepancies.

Data Extraction and Quality Assessment

Key information collected from the selected papers included the first author’s name, publication year, sample size, patient age, incidence rate of complications, and severity of complications. The quality of the trials and the risk of bias were assessed using the Robinson I tool, specifically designed for non-randomized intervention trials. Each bias segment, as well as the overall risk of bias, was rated as “low,” “medium,” or “serious.” Confounding factors were identified through consensus and referenced literature. 

Statistical Analysis

A meta-analysis was performed using RevMan 5.3 software. The odds ratio (OR) and its 95% confidence interval (CI) were calculated using either a random-effects or fixed-effects model, depending on the data type (binary or sequential). The I2 statistic was used to determine the degree of heterogeneity, with values above 50% favoring a fixed-effects model. A significance level of p < 0.05 was employed to assess statistical significance across subgroups.

Reporting Bias Assessment

Statistical and qualitative assessments of reporting bias were conducted through an Egger regression test and a funnel plot analysis. These methods examined the log odds ratio relative to its standard error, with no survey bias considered if p ≥ 0.05.

Deterministic Assessment

Each p-value was assessed using a two-tailed test. Graphics and statistics were generated using Review Manager V5.3.


Out of a total of 256 relevant studies, 11 publications met the criteria for inclusion and were reviewed. These publications span from 2010 to June 2023. The study initially involved 16,095 patients who had undergone surgical treatment for stomach cancer at the beginning of the research, with 1,263 undergoing robot-assisted procedures and 14,832 undergoing open surgical procedures. The sample sizes across the studies varied, ranging from 12 to 8,585 subjects.

The study found no statistically significant difference in the incidence of postoperative abdominal abscess among patients with stomach carcinoma (OR, 0.91; 95% CI, 0.25, 3.36; p=0.89). The data also exhibited heterogeneity (I2=67%). Similarly, there were no statistically significant differences in the risk of postoperative hemorrhage (OR, 1.37; 95% CI, 0.69, 2.75; p=0.37), and the data showed no heterogeneity (I2=0%).

Furthermore, there was no significant distinction in the overall incidence of postoperative complications between robot-assisted surgery and open surgical procedures for stomach carcinoma (OR, 0.78; 95% CI, 0.52, 1.18; p=0.24), with a degree of heterogeneity (I2=31%). The occurrence of wound dehiscence following robot-assisted operations in cases of stomach carcinoma displayed an odds ratio of 1.28 (95% CI, 0.75, 2.21; p=0.36) and had a degree of heterogeneity (I2=28%). The rate of wound infection after robotic surgery compared to open procedures showed similar results, with an odds ratio of 1.14 (95% CI, 0.78, 1.66; p=0.49).

Due to missing data, such as sex, age, and ethnic origin, the study could not investigate the impact of these factors on surgical outcomes. No evidence of bias was observed in the study, as indicated by quantitative Egger regression and funnel plot visualization (p>0.05). 

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