Surgical Techniques and Related Perioperative Outcomes After Robot-assisted Minimally Invasive Gastrectomy (RAMIG): Results From the Prospective Multicenter International Ugira Gastric Registry.

OBJECTIVE: To gain insight in global practice of RAMIG and evaluated perioperative outcomes using an international registry. BACKGROUND: The techniques and perioperative outcomes of robot-assisted minimally invasive gastrectomy (RAMIG) for gastric cancer vary substantially in literature. METHODS: Prospectively registered RAMIG-cases for gastric cancer (≥10 per center) were extracted from 25 centers in Europe, Asia and South-America. Techniques for the resection, reconstruction, anastomosis and lymphadenectomy were analyzed, and related to perioperative surgical and oncological outcomes. Complications were uniformly defined by the Gastrectomy Complications Consensus Group. RESULTS: Between 2020-2023, 759 patients underwent total (n=272), distal (n=465) or proximal (n=22) gastrectomy (RAMIG). After total gastrectomy with Roux-en-Y-reconstruction, anastomotic leakage rates were 8% with hand-sewn (n=9/111) and 6% with linear stapled anastomoses (n=6/100). After distal gastrectomy with Roux-en-Y (67%) or Billroth-II-reconstruction (31%), anastomotic leakage rates were 3% with linear stapled (n=11/433) and 0% with hand-sewn anastomoses (n=0/26). Extent of lymphadenectomy consisted of D1+ (28%), D2 (59%) or D2+ (12%). Median nodal harvest yielded 31 nodes [IQR 21-47] after total and 34 nodes [IQR 24-47] after distal gastrectomy. R0-resection rates were 93% after total and 96% distal gastrectomy. Hospital stay was 9 days after total and distal gastrectomy, and was 3 days shorter without perianastomotic drains versus routine drain placement. Postoperative 30-day mortality was 1%. CONCLUSIONS: This large multicenter study provided a worldwide overview of current RAMIG-techniques with their respective perioperative outcomes. These outcomes demonstrated high surgical quality, set a quality standard for RAMIG and can be considered an international reference for surgical standardization.

Thoraco-laparoscopic esophagectomy: thoracic stage in prone position.

OBJECTIVE: to analyze the National Cancer Institute Abdominopelvic Division (INCA / MS/HC I) initial experience with thoraco-laparoscopic esophagectomy with thoracic stage in prone position. METHODS: we studied 19 consecutive thoraco-laparoscopic esophagectomies from may 2012 to august 2014, including ten patients with squamous cells carcinoma (five of the middle third and five of the lower third) and nine cases of gastroesophageal junction adenocarcinoma (six Siewert I and three Siewert II). All procedures were initiated by the prone thoracic stage. RESULTS: There were minimal blood loss, optimal mediastinal visualization, oncological radicality and no conversions. Surgical morbidity was 42 %, most being minor complications (58% Clavien I or II), with few related to the technique. The most common complication was cervical anastomotic leak (37%), with a low anastomotic stricture rate (two stenosis: 10.53%). We had one (5.3%) surgical related death, due to a gastric tube`s mediastinal leak, treated by open reoperation and neck diversion. The median Intensive Care Unit stay and hospital stay were two and 12 days, respectively. The mean thoracoscopic stage duration was 77 min. Thirteen patients received neoadjuvant treatment (five squamous cells carcinoma and eight gastroesophageal adenocarcinomas). The average lymph node sample had 16.4 lymph nodes per patient and 22.67 when separately analyzing patients without neoadjuvant treatment. CONCLUSION: the thoraco-laparoscopic approach was a safe technique in the surgical treatment of esophageal cancer, with a good lymph node sampling.

Thoraco-laparoscopic esophagectomy: thoracic stage in prone position / Esofagectomia vídeo-tóraco-laparoscópica com tempo torácico em posição pronada

ABSTRACT Objective: to analyze the National Cancer Institute Abdominopelvic Division (INCA / MS/HC I) initial experience with thoraco-laparoscopic esophagectomy with thoracic stage in prone position. Methods: we studied 19 consecutive thoraco-laparoscopic esophagectomies from may 2012 to august 2014, including ten patients with squamous cells carcinoma (five of the middle third and five of the lower third) and nine cases of gastroesophageal junction adenocarcinoma (six Siewert I and three Siewert II). All procedures were initiated by the prone thoracic stage. Results: There were minimal blood loss, optimal mediastinal visualization, oncological radicality and no conversions. Surgical morbidity was 42 %, most being minor complications (58% Clavien I or II), with few related to the technique. The most common complication was cervical anastomotic leak (37%), with a low anastomotic stricture rate (two stenosis: 10.53%). We had one (5.3%) surgical related death, due to a gastric tube`s mediastinal leak, treated by open reoperation and neck diversion. The median Intensive Care Unit stay and hospital stay were two and 12 days, respectively. The mean thoracoscopic stage duration was 77 min. Thirteen patients received neoadjuvant treatment (five squamous cells carcinoma and eight gastroesophageal adenocarcinomas). The average lymph node sample had 16.4 lymph nodes per patient and 22.67 when separately analyzing patients without neoadjuvant treatment. Conclusion: the thoraco-laparoscopic approach was a safe technique in the surgical treatment of esophageal cancer, with a good lymph node sampling.

RESUMO Objetivo: analisar a experiência inicial do Serviço de Cirurgia Abdomino-Pélvica do Instituto Nacional de Câncer (INCA/MS/HC I) na esofagectomia vídeo-tóraco-laparoscópica com tempo torácico pronado. Métodos: estudo de 19 esofagectomias vídeo-tóraco-laparoscópicas realizadas de maio de 2012 a agosto de 2014, em dez pacientes portadores de carcinoma epidermoide esofágico (cinco do 1/3 médio e cinco do 1/3 inferior) e em nove portadores de adenocarcinoma da cárdia (seis Siewert I e três Siewert II). Todas as cirurgias foram iniciadas pelo tempo torácico em posição pronada, com mínima perda sanguínea, adequada visualização das estruturas mediastinais, radicalidade oncológica e sem conversões. Resultados: a morbidade cirúrgica foi de 42%, sendo a maioria complicações menores (58% Clavien I ou II). A complicação mais comum foi a fístula cervical em sete casos (37%), com baixa incidência de estenose anastomótica (duas estenoses: 10,53%). Houve um óbito (5,3%), relacionado a uma fístula mediastinal do tubo gástrico, tratada com reoperação e exteriorização cervical. As medianas de permanência em Centro de Terapia Intensiva e hospitalar foram respectivamente dois e 12 dias. A mediana do tempo vídeo-toracoscópico foi de 77min. Treze pacientes (68.4%) receberam tratamento neoadjuvante (cinco portadores de carcinomas epidermoides e oito de adenocarcinomas cárdia). A amostragem linfonodal média foi de 16,4 linfonodos por paciente e 22,67 quando analisados isoladamente os casos que não receberam tratamento neoadjuvante. Conclusão: a técnica vídeo-tóraco-laparoscópica se mostrou método seguro no tratamento cirúrgico do câncer do esôfago e proporcionou boa amostragem linfonodal em nossa casuística inicial.

Effects of TachoSil and 5-fluorouracil on colonic anastomotic healing.

BACKGROUND: The administration of intraperitoneal (IP) 5-fluorouracil (5-FU) during the early postoperative period after cytoreductive surgery can decrease local cancer recurrence but may also cause impairment of the anastomotic healing. This study examined the effects of the use of this therapy and of the anastomotic sealing with TachoSil, a fibrin-thrombin coated sealant (FTCS), on the healing of colon anastomoses. MATERIALS AND METHODS: Forty male rats were divided into four groups (1-4, 10 rats each) that underwent transection and anastomosis of the left colon. The anastomoses were covered with FTCS in groups 2 and 4. Saline solution (2 mL/d-groups 1 and 2) or 5-FU (20 mg/kg/d; groups 3 and 4) was administered IP once daily for 3 d. Bursting pressure (BP) was recorded, and the anastomoses were examined macroscopically and graded histologically. RESULTS: The relative weight loss was significantly higher in group 3 than in the other groups (P = 0.0004). Anastomotic dehiscence, postoperative adhesion formation, perianastomotic collections, and preanastomotic dilatation did not differ significantly among groups. BP was significantly lower in group 3 compared with all other groups (P = 0.001). Neoangiogenesis was significantly lower in group 3 compared with groups 1 and 2 (P = 0.05). Fibroblastic activity was significantly higher in group 1 compared with group 3 (P = 0.035). Inflammatory cell infiltration and collagen deposition did not differ significantly among groups. CONCLUSIONS: Our results shown that the early postoperative IP chemotherapy with 5-FU impaired the healing of colon anastomoses. However, anastomotic sealing with FTCS reversed some of the negative effects of this therapy.

Aggressive surgical approach to treat Gallbladder cancer: is it worth it?

The treatment of locally advanced gallbladder cancer has shifted in the past years, leading to a more aggressive surgical approach. We report a case of a 61-year-old woman diagnosed as having a locally advanced gallbladder cancer who was submitted to an aggressive surgical procedure in order to achieve complete resection (R0 resection). At laparotomy, a huge gallbladder tumor was seen with gross invasion of the transverse colon, distal part of stomach, pancreatic head, duodenum and liver. No distant metastases were seen. Surgical approach consisted in an en bloc tumor resection, including pancreatoduodenectomy, distal gastrectomy, right colectomy, hepatic resection (segments IVb, V and VI) and radical lymphadenectomy. The final pathology report revealed adenocarcinoma of the gallbladder with invasion to the nearby organs (liver, stomach, duodenum, head of the pancreas and colon) and no lymph nodes metastases (T4N0M0). All margins were free (R0 resection). Adjuvant chemotherapy was given (cisplatin and gemcitabine). The patient had been well (asymptomatic and with good quality of life) for 10 months when developed liver metastases not amenable to resection. The patient is being treated with palliative chemotherapy (gemcitabine and oxaliplatin). A marked improvement in outcome (survival and quality of life) of patients with gallbladder cancer has been achieved over the past years, primarily due to a shift towards more aggressive surgery. Therefore, this approach might be beneficial for selected patients with locally advanced gallbladder cancer.