To the Editors
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.
First, in Table 1, there was a statistically significant difference in age between the two groups of patients (P<0.001), and patients over 80 years old in the laparoscopic gastrectomy group were higher than those in the robotic gastrectomy group. 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<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.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.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 ɑ(TNF-ɑ), which further aggravates the body’s metabolic process.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%.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.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.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.10 Some studies have also found that combined cholecystectomy is an independent risk factor for serious complications after laparoscopic distal gastrectomy in the elderly.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.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 2.14 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.15.16 This increases the incidence of postoperative complications, slows down postoperative recovery, and even leads to more serious complications such as organ failure.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.