1. ROBOTIC VERSUS LAPAROSCOPIC SLEEVE GASTRECTOMY FOR MORBID OBESITY: A META-ANALYSIS Background Results Methods Conclusion Kandace Kichler, MD; Jessica L Buicko, MD; Lucy De La Cruz, MD; Leonardo Tamariz, MD, MPH; Srinivas Kaza, MD, FACS University of Miami Palm Beach Regional Campus – Department of Surgery, Atlantis, FL References A MEDLINE database search was performed with secondary referencing to identify studies suitable for inclusion. Selected studies included those in which RSG and LSG were compared in terms of perioperative outcomes. A two researcher manual analysis of selected papers was carried out. Evaluated variables included operative time, perioperative bleeding, length of stay, stricture formation, leak rate, and mean BMI after one year. We calculated the I-squared statistic as a measure of heterogeneity. We used two different pooled statistics. Relative risk (RR) was determined for categorical outcomes, and standardized mean difference (SMD) was calculated for continuous outcomes. Sleeve gastrectomy (SG) represents the fastest growing bariatric surgical procedure currently performed worldwide for morbid obesity. As compared to other bariatric surgical procedures, SG is considered relatively simple, safe, and with few long term complications. [2,3] In addition, SG provides the opportunity to act as a bridge for future operations in the super obese. [1] Currently, the most popular SG approach to date is laparoscopic. With the technological advancement of the da Vinci Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA), many surgeons have adopted the robotic technique. Advantages of the robotic platform include increased visualization, maneuverability, and better triangulation. [6] The purpose of this meta-analysis is to compare the clinical safety and efficacy of robotic sleeve gastrectomy (RSG) with laparoscopic sleeve gastrectomy (LSG). Robotic sleeve gastrectomy for morbid obesity as compared to LSG shows a significantly increased operative time. In regards to mean BMI at one year, RSG is superior to LSG. There was no significant difference in terms of LOS, perioperative bleeding, leak rate, or stricture formation. RSG is a safe and feasible alternative to conventional LSG. Further comparative studies may shed additional light on perioperative outcomes. 1.Ayloo S1, Buchs NC, Addeo P, Bianco FM, Giulianotti PC. Robot-assisted sleeve gastrectomy for super-morbidly obese patients. J Laparoendosc Adv Surg Tech A. 2011 May;21(4):295-9. 2.Cirocchi R, et al. Current status of robotic bariatric surgery: a systematic review. BMC Surg. 2013 Nov 7;13:53. 3.Diamantis T1, Alexandrou A, Nikiteas N, Giannopoulos A, Papalambros E. Initial experience with robotic sleeve gastrectomy for morbid obesity. Obes Surg. 2011 Aug;21(8):1172-9. 4.Romero RJ, et al. Robotic sleeve gastrectomy: experience of 134 cases and comparison with a systematic review of the laparoscopic approach. Obes Surg. 2013 Nov;23(11):1743-52. 5.Schraibman V1, et al. Comparison of the Morbidity, Weight Loss, and Relative Costs between Robotic and Laparoscopic Sleeve Gastrectomy for the Treatment of Obesity in Brazil. Obes Surg. 2014 Mar 23. 6.Vilallonga R, Fort JM, Caubet E, Gonzalez O, Armengol M. Robotic sleeve gastrectomy versus laparoscopic sleeve gastrectomy: a comparative study with 200 patients. Obes Surg. 2013 Oct;23(10):1501-7. Four studies matched the selection criteria and reported on a total of 3599 cases. Of these, 280 cases were RSG and 3319 were LSG. Comparing RSG to LSG, we found favorable outcomes in regards to mean BMI after one year (SMD: -0.243; 95% CI: - 0.466 - -0.019; p = 0.033). However, operative time was increased (SMD: 0.494; 95% CI: 0.245-0.743; p < 0.01). Other results were not significant, including leak rate (RR: 0.433; 95% CI: 0.115-1.638; p = 0.218); perioperative bleeding (RR: 0.578; 95% CI: 0.161-2.075; p = 0.401); stricture formation (RR: 1.809; 95% CI: 0.249- 13.132; p = 0.558); and length of stay (SMD: -0.062; 95% CI: -0.637-0.513; p = 0.833) (Table 2). Table 1. Characteristics of Studies in Meta-Analysis Study Type of Study Year CountryNo. of Patients Age (mean) BMI (kg/m2) Operative Time (mins) Length of Stay (days) Complications (Bleeding, Leak, Stricture) BMI after 1 Year (kg/m2) LSGRSGLSGRSGLSGRSGLSGRSGLSGRSGLSGRSGLSGRSG Ayloo Prospective2011US393038 56.0±11.757.0±10.71141352.42.60143±10.439±8.8 Romero Retrospective2013US3148134414343.6±8.145.0±7.1951073.32.21081-- Schraibman Prospective2014Brazil3216464339.4±3.841.3±4.51381483.0 0029.2±0.627.1±0.9 Vilallonga Prospective2013Spain100 434447.0±6.048.0±8.0961083.04.08533±2.032±7.0 Length of Stay BMI after 1yr Bleeding LeakStricture 0.24 (-0.24, 0.71) 23.80 -0.66 (-0.83, -0.49) 27.76 0.00 (-0.60, 0.60) 27.71 0.24 (-0.04, 0.52) 26.70 -0.06 (-0.64, 0.51) 100.0 Ayloo Schraibman Vilallonga Overall (p = 0.033) -0.41 (-0.89, 0.07) 21.57 -0.21 (-0.81, 0.39) 13.79 -0.19 (-0.47, 0.08) 64.64 -0.24 (-0.47, -0.02) 100.00 Romero Schraibman Overall (p = 0.401) 0.69 (0.10, 5.01) 40.97 0.50 (0.09, 2.67) 59.03 0.58 (0.16, 2.07) 100.00 Romero Vilallonga Overall (p = 0.218) 0.19 (0.01, 3.90) 56.23 0.75 (0.17, 3.27) 43.77 0.43 (0.11, 1.64) 100.00 Ayloo Romero Overall (p = 0.558) 3.87 (0.16, 91.80) 29.82 0.93 (0.06, 15.68) 70.18 1.81 (0.25, 13.13) 100.00 Table 2. Meta-Analysis Results Ayloo Romero Schraibman Vilallonga Overall (p = 0.833) Operative Time Ayloo Romero Schraibman Vilallonga Overall (p < 0.01) 0.75 (0.26, 1.24) 16.91 0.30 (0.13, 0.47) 40.22 0.36 (-0.25, 0.96) 12.67 0.67 (0.38, 0.95) 30.20 0.49 (0.25, 0.74) 100.00