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\begin{document}

\title{Short-term outcomes of laparoscopic and robotic distal gastrectomy for
gastric cancer}



\author[1]{Feng Xu}%
\author[2]{Xi Yang}%
\author[3]{Qiang Hu}%
\affil[1]{Hangzhou Ninth People's Hospital}%
\affil[2]{Community Health Service Center of Guali Town of Xiaoshan}%
\affil[3]{Tongde Hospital of Zhejiang Province}%


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  \date{June 11, 2024}


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\begin{abstract}
We have read with interest the article published by Hondo N et al.1 At
present, there are several minimally invasive surgical methods for the
treatment of gastric cancer: Endoscopic mucosal resection (EMR) ,
Endoscopic submucosal dissection (ESD), Laparocopy-assisted radial
gastrectomy (LARG), and Robot-assisted radical gastrectomy (RARG). LARG
and RARG can not only be used for early gastric cancer, but also for the
treatment of advanced gastric cancer, and they have the advantage of a
wide range of surgical indications. Laparoscopic surgery also has some
drawbacks, including a two-dimensional surgical field of view and
limited operational freedom. In order to improve the above shortcomings,
the da Vinci robotic surgical system has emerged in response to the
times. The da Vinci surgical robot system is currently the most advanced
high-tech platform for minimally invasive surgery internationally. It
solves the limitations of traditional laparoscopy in terms of field of
view and operational flexibility, and breaks through the bottleneck of
limited development in traditional laparoscopic surgery. Although we
believe it is a very interesting topic, we would like to offer the
following points for your consideration.%
\end{abstract}%



\sloppy


\textbf{Short-term outcomes of laparoscopic and robotic distal
gastrectomy for gastric cancer}

Feng Xu MD, Xi Yin Yang MD, Qiang Hu MD,

Feng Xu MD

Department of general surgery, Hangzhou Ninth People's Hospital

Xi Yin Yang MD

Department of Traditional Chinese Medicine,Community Health Service
Center of Guali Town of Xiaoshan

Correspondence:Qiang Hu MD,

Department of general surgery,Tongde~Hospital~of~Zhejiang~Province

E-mail:15700190534@163.com.

\textbf{To the Editors}

We have read with interest the article published by Hondo N et
al.\textsuperscript{1} At present, there are several minimally invasive
surgical methods for the treatment of gastric cancer: Endoscopic mucosal
resection (EMR) , Endoscopic submucosal dissection (ESD),
Laparocopy-assisted radial gastrectomy (LARG), and Robot-assisted
radical gastrectomy (RARG). LARG and RARG can not only be used for early
gastric cancer, but also for the treatment of advanced gastric cancer,
and they have the advantage of a wide range of surgical indications.
Laparoscopic surgery also has some drawbacks, including a
two-dimensional surgical field of view and limited operational freedom.
In order to improve the above shortcomings, the da Vinci robotic
surgical system has emerged in response to the times. The da Vinci
surgical robot system is currently the most advanced high-tech platform
for minimally invasive surgery internationally. It solves the
limitations of traditional laparoscopy in terms of field of view and
operational flexibility, and breaks through the bottleneck of limited
development in traditional laparoscopic surgery. Although we believe it
is a very interesting topic, we would like to offer the following points
for your consideration.

First, \textbf{in Table 1,} there was a statistically significant
difference in age between the two groups of patients
(P\textless{}0.001), and patients over 80 years old in the laparoscopic
gastrectomy group were higher than those in the robotic gastrectomy
group. \textbf{In Table 2,} the results of the multivariate analysis for
individuals over 80 years old are (OR=2.28, 95\% CI: 1.251-3.49,
P\textless{}0.001). This indicates that increasing age is an independent
risk factor for postoperative complications in gastric cancer. The
increase in age may reduce the ability of elderly people to resist
surgical trauma, including a decrease in immunity, pain tolerance, and
body recovery ability, leading to an increased incidence of
postoperative complications and longer hospital
stays.\textsuperscript{2} The conclusion of this study confirms that the
hospitalization time of the laparoscopic gastrectomy group is longer
than that of the robotic gastrectomy group, but further exclusion of the
influence of age on the conclusion of this study is needed.

Second, in Table 1, the nutritional evaluations of the two groups were
not provided, such as nutrition risk screening 2002(NRS-2002) score,
albumin level, hemoglobin level, etc. Tumor progression is often
accompanied by uncontrolled consumption of nutrients, leading to
malnutrition in patients with malignant tumors.\textsuperscript{3} Due
to the unique location of the lesion, gastric cancer patients often
suffer from obstacles in nutrient uptake, digestion, and absorption. At
the same time, gastric cancer cells also release some cytokines, such as
tumor necrosis factor a\selectlanguage{english}(TNF-a\selectlanguage{english}), which further aggravates the body's
metabolic process.\textsuperscript{4} Compared to other non
gastrointestinal tumor patients, malnutrition is more common in gastric
cancer patients, with an incidence rate reported in the literature
ranging from 29.1\% to 80.4\%.\textsuperscript{5} Nutritional status is
an important factor affecting postoperative recovery of the body.
Malnutrition can affect the healing of surgical incisions, reduce the
body's ability to resist infections, increase postoperative
complications, and further lead to prolonged hospitalization. At the
same time, it can also affect the quality of life and clinical outcomes
of patients. For patients with nutritional risk and malnutrition, timely
nutritional intervention should be carried out. They have important
clinical significance in promoting early recovery of patients, reducing
postoperative complications, and improving long-term prognosis.

Third, in Table 1, the number of lymph node dissection were not given
for both groups. We all know that a larger number of lymph node
dissection can improve the accuracy of tumor staging, resulting in more
accurate prognosis evaluation, and more thorough lymph node dissection
may lead to better prognosis.\textsuperscript{6} But more thorough lymph
node dissection may indeed make blood vessels too naked and fragile,
making it prone to serious complications such as intra-abdominal
bleeding.\textsuperscript{7,8,9} These complications may lead to
prolonged hospital stay.

Fourth, in Table 1, the situation of combined resection of other organs
in both groups were not given. Studies have shown that gastric cancer
surgery with combined removal of other organs is one of the independent
risk factors for postoperative complications in gastric cancer.
Progressive gastric cancer often requires combined resection of other
organs, such as the spleen, pancreas, transverse colon, etc. These are
much more complex than just gastric resection, which brings excessive
surgical stress and is more prone to postoperative complications. A
randomized controlled clinical study has shown that combined splenectomy
and pancreatectomy are believed to be associated with an increased
incidence of postoperative complications and mortality in gastric
cancer.\textsuperscript{10} Some studies have also found that combined
cholecystectomy is an independent risk factor for serious complications
after laparoscopic distal gastrectomy in the
elderly.\textsuperscript{11} We suggest considering the patient's
condition comprehensively before surgery and carefully selecting
multiple organ resection. If a combined surgery with other organ
resection is required, surgical stress should be minimized as much as
possible, and attention should be paid to the patient's preoperative
preparation and postoperative condition changes to reduce the occurrence
of postoperative complications.

Fifth, in Table 1, the American Society of Anesthesiologists(ASA) scores
for both groups were not provided. The ASA score reflects the severity
of preoperative comorbidities.\textsuperscript{12,13} It categorizes the
risk of surgery based on the patient's preoperative physical condition,
and divides the patient into five levels before anesthesia. The higher
the level, the greater the surgical risk. Multivariate logistic
regression analysis shows that gastric cancer patients with ASA scores
above 3 have a significantly higher overall incidence of postoperative
complications compared to patients with ASA scores below
2.\textsuperscript{14} Patients with high ASA scores experience a
decrease in their ability to resist shocks and an increased incidence of
infection and organ dysfunction after undergoing gastric resection
surgery.\textsuperscript{15.16} This increases the incidence of
postoperative complications, slows down postoperative recovery, and even
leads to more serious complications such as organ
failure.\textsuperscript{17} For patients with high ASA scores, adequate
preparation must be made before surgery, including the patient's
physical and psychological preparation. Only in this way can the patient
smoothly pass the perioperative period.

\textbf{CONFLICT OF INTERESTS}

The authors declare that there are no conflict of interests.

\textbf{REFERENCES}

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\tightlist
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\end{enumerate}

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