Robotic Surgery for Gastrointestinal Malignancies—A Review of How Far Have We Come in Pancreatic, Gastric, Liver, and Colorectal Cancer Surgery

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This article presents a thorough review of the literature on robot-assisted surgery for pancreatic, gastric, liver, and colorectal cancers, encompassing perioperative, short-term, and long-term outcomes associated with these cancers. This systematic assessment aids in comprehending the present state and efficacy of robot-assisted surgery. The authors meticulously gathered and synthesized the extant evidence, underscoring the benefits of robot-assisted surgery, including reductions in conversion to open surgery rates, diminished intraoperative bleeding, and abbreviated hospital stays. Concurrently, they spotlighted drawbacks such as extended operation durations and elevated costs. The article accentuates that the majority of existing studies are retrospective, with notably variable data quality, particularly concerning pancreatic and liver surgery. This indicates a pressing need for more randomized controlled trials (RCTs) to substantiate the impacts of robot-assisted surgery. The authors elaborated that the utilization of the robotic platform is most sophisticated in colorectal cancer interventions, whereas it remains comparatively nascent in pancreatic and liver surgeries. This mirrors the disparities in the uptake of robot-assisted surgery across diverse cancer types. It is recommended that the author revise the manuscript in accordance with the following comments.

1. It is recommended that the author allocate additional space in the introduction to provide comprehensive background information on robot-assisted surgery.
2. The following references are highly relevant to the author's research topic and are recommended for citation.

[1] Cunha Reis T. The roadblocks to AI adoption in surgery: data, real-time applications and ethics. Med Adv. 2024; 2(4): 380–3. https://doi.org/10.1002/med4.82

[2] J. Li, A. Gu, N. Tang, G. Zengin, M.-Y. Li, Y. Liu, Patient-derived xenograft models in pan-cancer: From bench to clinic. Interdiscip. Med. 2025, 3, e20250016. DOI: 10.1002/INMD.20250016

[3] Raj, G.M., Dananjayan, S. and Gudivada, K.K. (2024), Applications of artificial intelligence and machine learning in clinical medicine: What lies ahead?. Med. Adv, 2: 202-204. https://doi.org/10.1002/med4.62

3. To enhance the precision of the evaluation, it is advisable to include data from recently published, high-quality studies that mirror the most recent advancements and efficacy of robot-assisted surgery.
4. Additional prospective randomized controlled trials, particularly for intricate surgeries such as pancreas and liver, should be carried out to furnish more robust data support for its enduring therapeutic effect.
5. The discourse regarding the learning curve for robotic surgery is expanding, with a focus on analyzing its duration and strategies to mitigate complications during this period. This will subsequently enhance the overall feasibility of the surgical procedure.
6. This study presents a comprehensive comparison of the cost-effectiveness between robot-assisted surgery and traditional surgery, incorporating factors such as surgical fees, duration of hospital stay, and recovery time. The aim is to facilitate healthcare decision-makers' comprehension of the economic justification for robotic surgery.

Author Response

Please see the attached file.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The paper presented by our surgical colleagues aims to review the results achieved with robotic surgery, which procedures provide the best results, and the best short- and long-term prognosis for this type of access. The abstract is very clear and immediately conveys the thinking behind the entire study. Regarding the procedures considered, we must state that: the authors were objective in considering the procedures performed with the robot. There are no published data on the pancreas yet that allow us to understand the real advantages of robotic access beyond those universally recognized. Distal pancreatectomy cannot be compared to pancreaticoduodenectomy, which remains the most complex surgical procedure due to the involved structures of the splanchnic area. Certainly, the experience of numerous cases in high-volume tertiary centers will contribute to the understanding of a working methodology that can improve the short- and long-term outcomes of these procedures. We must remember that pancreatic surgery is still treacherous, and many have considered avoiding it surgically, given that survival is often better in untreated patients. Regarding gastric surgery, we agree with the authors' comments, keeping in mind that the procedure's primary benefit is lymphadenectomy, which we know to be the cornerstone of the operation and subsequent prognosis. The learning curve has also been shortened with the experience of some, although costs remain high (doi: 10.3390/curroncol32020083. To be read and cited in the bibliography). Regarding robotic liver surgery, as written, we can consider it reductive; in fact, we must make a distinction. There is surgery for hepatolithiasis, for cholangiocarcinoma, and finally for hepatocellular carcinoma. The results for the three conditions are comparable but different. We completely agree with what's been written about the colorectal region, especially the latter, which is undoubtedly the procedure that has benefited most from robotic surgery due to the complexity of preserving the structures possible in a narrow field, magnified by the camera, both because it's 3D and because of the increased dimensions, not least because of the position of the first surgeon, who, in a lengthy procedure, can proceed in a more comfortable position. As already published in numerous studies, the best results will be achieved for a borderline pathology. The conclusions are largely shared, even if the secret to robotic surgery's success lies in the industry's lowering of prices, and this can be achieved with greater competition on the one hand, and by concentrating robotic cases in hospitals selected for their highest volume, on the other, we can reduce costs. There's no doubt that this type of access is a winning option not only for the procedures described but also for pathologies such as the esophagus, lung, prostate, and uterus. Progress cannot be stopped, but rather managed. Good English, good bibliography, good iconography

Author Response

Please see the attached file.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript titled “Robotic Surgery for Gastrointestinal Malignancies – A Review of How Far Have We Come in Pancreatic, Gastric, Liver, and Colorectal Cancer Surgery” is well written and presented.

This study shows that highest-quality evidence supports the robotic approach in rectal cancer, demonstrating clear functional and oncologic benefits.

This manuscript is recommended for acceptance after a minor revision to improve clarity and incorporate specific feedback, authors please provide explanations:

1. In this study, there is a lack of randomized controlled trials (RCTs) providing high-level evidence for most gastrointestinal malignancies.
2. The learning curve and variability in surgeon experience may have influenced perioperative and oncological outcomes.
3. Publication bias cannot be ruled out, as studies with favorable results are more likely to be reported.
4. There are limited long-term follow-up data restricts conclusions regarding overall and disease-free survival benefits.
5. Most included studies are retrospective and single-institutional, leading to potential selection bias and limited generalizability.
6. Considerable heterogeneity exists among study designs, patient populations, and outcome measures, making cross-comparisons difficult.

Author Response

Please see the attached file.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

fine paper endorse for publication