title: Minimally invasive surgery for gastric cancer: the American experience.
abstract: BACKGROUND
  Minimally invasive surgical techniques are increasingly being implemented in oncologic care. This study assesses the impact of minimally invasive surgery on oncologic and perioperative outcomes in the management of gastric cancer in the USA.
  
  
  METHODS
  From the American College of Surgeons and American Cancer Society National Cancer Data Base, we identified 6427 patients who underwent gastrectomy for cancer from 2010 to 2012. Treatment groups were categorized with an intention-to-treat paradigm as robotic, laparoscopic, and open surgery. Univariate and multivariate analyses were performed to estimate the impact of the surgical approach on oncologic and perioperative outcomes.
  
  
  RESULTS
  Of patients undergoing definitive surgical intervention, 3.5 % (n = 223) underwent robotic gastrectomy, 23.1 % (n = 1487) underwent laparoscopic gastrectomy, and 73.4 % (n = 4717) underwent open surgery. Minimally invasive gastrectomy was more frequently performed on white (P = 0.018), privately insured patients (P = 0.049) treated at academic centers (P < 0.0001) in the eastern USA (P < 0.0001). After demographics, comorbidities, and tumor-related factors had been controlled for, patients who underwent laparoscopic gastrectomy had the postoperative length of stay decreased by 1.08 days (P < 0.0001) and greater odds of having at least 15 lymph nodes resected (odds ratio 1.16, P = 0.023). Use of robotic surgery did not have a statistically significant effect on the postoperative length of stay relative to open surgery (P = 0.222) but the patients so treated had greater odds of having at least 15 lymph nodes resected (odds ratio 1.51, P = 0.005). There were no differences in R0 resection rates or perioperative mortality on the basis of the surgical approach alone.
  
  
  CONCLUSIONS
  These findings suggest that use of minimally invasive surgery for gastric cancer in the USA is impacting the adequacy of oncologic resection but is not yet having a clinically significant impact on perioperative outcomes relative to a conventional open approach.
authors.affiliation: Department of Surgery, The Pennsylvania State University College of Medicine, 500 University Drive, H070, Hershey, PA, 17033-0850, USA.
authors.forename: Erin K
authors.initials: EK
authors.lastname: Greenleaf
authors.affiliation: Department of Surgery, The Pennsylvania State University College of Medicine, 500 University Drive, H070, Hershey, PA, 17033-0850, USA.
authors.forename: Susie X
authors.initials: SX
authors.lastname: Sun
authors.affiliation: Department of Surgery, The Pennsylvania State University College of Medicine, 500 University Drive, H070, Hershey, PA, 17033-0850, USA.|Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA.
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Hollenbeak
authors.affiliation: Department of Surgery, The Pennsylvania State University College of Medicine, 500 University Drive, H070, Hershey, PA, 17033-0850, USA. jwong1@hmc.psu.edu.
authors.forename: Joyce
authors.initials: J
authors.lastname: Wong
mesh_terms: D000230:Adenocarcinoma / Q000556:secondary / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D005743:Gastrectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay; D008198:Lymph Nodes / Q000473:pathology / Q000601:surgery*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D060787:Neoplasm Grading; D009361:Neoplasm Invasiveness; D011379:Prognosis; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000379:methods*; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D015996:Survival Rate; D055815:Young Adult
keywords: Gastrectomy; Gastric cancer; Minimally invasive; Outcomes