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Exploring the Learning Curve of Minimally Invasive Total Gastrectomy – A Systematic Review

Authors
Kai Siang CHAN1,2, Aung Myint OO1,2,3

Affiliations

  1. Department of General Surgery, Tan Tock Seng Hospital, Singapore
  2. Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
  3. Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Introduction
Minimally-invasive total gastrectomy (MITG) has lower morbidity compared to open total gastrectomy with similar lymph node (LN) harvest. However, surgeons need to overcome the initial learning curve (LC) before reaping the benefits of MITG. This study aims to perform a pooled analysis on the number of cases required to surmount the LC (i.e. NLC) in MITG.

Methods
A systematic review on PubMed, Embase, Scopus and the Cochrane Library from inception till August 2022 was performed for studies reporting LC in laparoscopic total gastrectomy (LTG) and/or robotic total gastrectomy (RTG). Poisson means (95% confidence interval (CI)) was used to determine NLC. Negative binomial regression was used for comparative analysis.

Results
There were 12 articles with 18 data sets: 12 data sets (n=1202 patients) on LTG and 6 data sets (n=318 patients) on RTG. Majority of studies were conducted in East Asia (94.4%). Majority of data sets (n=12/18, 66.7%) used non-arbitrary analysis. The overall NLC was significantly smaller in RTG compared to LTG (RTG 20.5 (95% CI: 17.0-24.5); LTG 43.9 (95% CI: 40.2-47.8); Incidence rate ratio (IRR) 0.47, p<0.001). The NLC for operating time (OT) (IRR 0.50, 95% CI: 0.34-0.74) and LN harvest (IRR 0.42, 95% CI: 0.27-0.67) was also significantly lower for RTG compared to LTG. Subgroup analysis of LTG with splenic preservation showed NLC of 42.2 cases (n=5 data sets, 95% CI: 36.7-48.3). NLC was comparable between totally-laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG): LATG 39.0 (95% CI: 30.8-48.7; TLTG 36.0, (95% CI: 30.4-42.4).

Conclusion
LC for RTG is significantly shorter for LTG but may be due to more experience in the RTG group. Analysis is however limited by the small sample size.