Open versus laparoscopic versus robotic gastrectomy for cancer: need for comparative-effectiveness quality
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- Glantzounis, G., Ziogas, D. & Baltogiannis, G. Surg Endosc (2010) 24: 1510. doi:10.1007/s00464-009-0790-y
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New technologies and medical devices may improve both health care and research toward the development of new drugs. But they are a major driver of increases in U.S. health care expenditures, which have grown by an estimated 71% since 2000 . In an economic crisis, cost effectiveness for new therapies (e.g., robotic surgery) should be considered.
The U.S. market for drugs and devices is regulated by the Food and Drug Administration (FDA), which scrutinizes clinical trial data for evidence of safety and efficacy. Although the FDA has been criticized for missteps and inefficiencies in its approval process, more relevant is FDA oversight of the labeling and promotion of medical products.
Indeed, the FDA does not require the inclusion of statements regarding a product’s comparative effectiveness. Clinicians, patients, and payers would be less willing to pay more for a new treatment such as robotic surgery without proof that it improves health outcomes.
Comparative-effectiveness research is the current standard strategy for drawing robust conclusions about new drugs, medical devices, and surgical techniques . Randomized phase 3 trials are the best tools for ultimate decisions in medicine.
The current standard of care in the treatment of resectable gastric cancer includes gastrectomy and adjuvant chemotherapy with or without radiotherapy [3–5]. It is thought that the quality of surgery  including a standardized D2 lymphadenectomy can improve the survival of patients with stage 2 or 3 disease [7–12].
New techniques for improving patient outcomes include endoscopic submucosal resection for early gastric cancer, laparoscopic gastrectomy, and robotic surgery. All these new treatments should provide evidence of their superiority over open D2 gastrectomy before they are widely used.
Oncologic outcomes are the principal priority in the treatment of cancer patients. Although minimally invasive surgery improves quality of life (QOL), it should be ensured that these techniques do not increase recurrence risk and mortality.
In a recent issue of Surgical Endoscopy, Kim et al.  provided comparison-effectiveness information regarding robotic surgery versus laparoscopic or open gastrectomy for the treatment of gastric cancer. The authors compared the results of robotic gastrectomy using the da Vinci surgical system with those for 11 laparoscopic and 12 open gastrectomies performed during the same period (31 December 2007 to 30 June 2008).
At baseline, no significant difference in clinicopathologic characteristics or tumor stage was observed between the three groups. The total number of lymph nodes retrieved (TNODS) and used as a quality control measure in gastric, colorectal, and other cancers, did not differ significantly among the groups. Robotic surgery was associated with significantly less blood loss and a shorter postoperative hospital stay. The postoperative morbidity was similar in the three groups. No open or laparoscopic conversion was performed in the robotic group. Kim and colleagues concluded that experienced laparoscopic surgeons can safely perform robotic surgery for gastric cancer, improving the short-term outcomes.
This study provides encouraging data on the use of robotic surgery for gastric cancer. But it is a small retrospective with no information on long-term survival or cost-effectiveness analysis of robotic surgery versus laparoscopic or open gastrectomy.
New technologies may improve biomedical science and clinical practice. Applying high-throughput technology to discover the genetic bases of diseases including cancer is a first priority of Francis Collins, the new director of the U.S. National Institute of Health (NIH) . Personal genomics and quantitative genetics represent the major hope toward personalized management of cancer [15–28]. If personalized medicine achieves its goal to be translated into clinical practice, it is expected to change routine clinical practice, leading to dramatic improvement of oncologic outcomes [29–36].
Robotic surgery is undoubtedly the most promising way to improve the QOL of patients with solid tumors. But because of high costs, high-quality comparative-effectiveness research is required to assess the strengthens and disadvantages of robotic surgery compared with laparoscopic or open surgery. Until such research is conducted, a standardized open gastrectomy with D2 lymphadenectomy still remains the standard therapeutic approach for advanced stages 2 and 3 gastric cancer.
Georgios Baltogiannis, Dimosthenis Ziogas, and Georgios Glantzounis have no conflicts of interest or financial ties to disclose.