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Robotic RYGB vs LRYGB

Robotic RYGB provides no clinical advantages vs LRYGB

The researchers found that the robotic approach to RYGB did not result in a reduction in postoperative complications compared to laparoscopic approaches using hand-sewn or linear stapler
The rate of intraoperative complications was higher (1%) in the LRYGB-21CS group and included intraabdominal bleeding, compared to a complication rate of 0% in totally robotic Roux-en-Y gastric bypass group

Totally robotic Roux-en-Y gastric bypass offers no real clinical advantage compared to all laparoscopic RYGB (LRYGB) techniques, according to a study by researchers from the US and Poland. The researchers found that the robotic approach to RYGB did not result in a reduction in postoperative complications compared to laparoscopic approaches using hand-sewn or linear stapler for the gastrojejunal anastomosis, and the robotic approach also required significantly longer operative times than each of the alternate laparoscopic techniques. However, the LRYGB approach with the 21mm circular stapler did have a higher stricture rate resulting in a longer hospital stay and higher readmission rate, compared to the robotic approach.

The paper, ‘Does Robotic Roux-en-Y Gastric Bypass Provide Outcome Advantages over Standard Laparoscopic Approaches?’, published in Obesity Surgery, is believed to be the first study using propensity matching to compare the outcomes of totally robotic RYGB to different laparoscopic RYGB techniques with variations on construction of the GJA.

In total, 578 eight patients were included in this study and underwent totally robotic Roux-en-Y gastric bypass (n=103) or LRYGB (n=475). The LRYGB included 21mm EEA circular-stapled (21CS, n=125), linear-stapled (LS, n=300) and hand-sewn (HS, n=50) groups. The researchers collected data on operative time, length of hospital stay, one-year readmission and adverse events including intraoperative complications, return to the operating room within one year after surgery, and early and intermediate complications (including GJA leaks, GJA strictures) among others.

Outcomes

After propensity score matching, the median follow-up was 193 days in totally robotic Roux-en-Y gastric bypass and 368 days in LRYGB-21CS group (p<0.001). The mean age of patients in totally robotic Roux-en-Y gastric bypass group (n=82) was 43.0±11.3 years, compared with 42.0±11.8 years in the LRYGB-21CS (n=82) group. The mean BMI in totally robotic Roux-en-Y gastric bypass group was 48.5±7.0, compred to the mean BMI in LRYGB-21CS group of 48.0±7.0. There were no other notable differences between groups regarding comorbidities.

The researchers report that the operative time was significantly longer in totally robotic Roux-en-Y gastric bypass group (204±36 mins vs 139± 30, p<0.001), but the rate of intraoperative complications was higher (1%) in the LRYGB-21CS group and included intraabdominal bleeding, compared to a complication rate of 0% in totally robotic Roux-en-Y gastric bypass group. The mean length of hospital stay was significantly shorter in totally robotic Roux-en-Y gastric bypass group in comparison to LRYGB-21CS group (2.6±1.2 vs. 4.3±5.5 days, p=0.008).

Furthermore, the readmission rate was significantly lower in totally robotic Roux-en-Y gastric bypass group (12 vs. 28%, p=0.009), these patients also reported less vomiting episodes compared with LRYGB-21CS (15 vs. 33%, p=0.005) and the incidence of anastomosis stricture was significantly lower in totally robotic Roux-en-Y gastric bypass patients (2 vs. 17%, p=0.003).

Mean %TWL after one year was significantly lower in totally robotic Roux-en-Y gastric bypass patients (− 20.7±10.6 vs. − 25.1±10.6, p=0.02) and the mean BMI change after surgery was also significantly lower in totally robotic Roux-en-Y gastric bypass patients (− 10.3±5.3 vs. − 12.3±5.2, p=0.01). Although the researchers note that the incidence of marginal ulcer was not statistically significant (12 vs. 23%, p=0.09), but possibly “clinically important”.

Total operative time was significantly longer in totally robotic Roux-en-Y gastric bypass group (206±37 min vs. 158±30 min, p<0.001) and the rate of intraoperative complications was 0% in totally robotic Roux-en-Y gastric bypass and 2% in LRYGB-LS. There was no statistical difference in mean length of hospital stay in totally robotic Roux-en-Y gastric bypass (2.5±1.1 vs. 2.8±1.0 days, p=0.06). They report that the readmission rate was comparable between totally robotic Roux-en-Y gastric bypass and LRYGB-LS (13 vs. 11%, p=0.64).

Total operative time was significantly longer in totally robotic Roux-en-Y gastric bypass group (210±36 min vs. 167±30 min, P<0.001). The rate of intraoperative complications was 2% in totally robotic Roux-en-Y gastric bypass and 10% in LRYGB-LS, although this is based on small sample sizes (p=0.32). The researchers found no difference in mean length of hospital stay in totally robotic Roux-en-Y gastric bypass (2.9±1.6 vs. 3.6±2.9 days, p=0.25).The readmission rate was comparable between totally robotic Roux-en-Y gastric bypass and LRYGB-HS groups (15 vs. 14%, p=0.97), although no statistical differences were observed in the incidence of anastomosis leak, anastomosis stricture, and other complications.

In response to their findings, the researchers currently employ LRYGB-LS and LRYGB-HS methods or the 25-mm diameter CS for creation of the GJA.

The authors acknowledge that the study is limited by its retrospective, non-randomised, single centre design. Moreover, as the study concentrated on early outcomes and postoperative complications, the results cannot be extrapolated to long-term outcomes.

“These findings suggest that totally robotic RYGB currently provides no clinical advantages over laparoscopic techniques for RYGB and increases operative time and resources,” the authors conclude. “Randomised controlled trials directly comparing robotic vs. laparoscopic approaches are needed before the robotic approach to RYGB can be considered an alternative to standard laparoscopic approaches.”

To access this paper, please click here

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