Robotic gastrectomy using hinotori™ Surgical Robot System: Initial case series.

BACKGROUND: This study aims to prove the feasibility and safety of robotic gastrectomy using the hinotori™ Surgical Robot System (Medicaroid Corporation, Kobe, Japan). METHODS: We retrospectively enrolled the 16 patients who underwent gastrectomy by the hinotori™ Surgical Robot System for gastric cancer at our hospital between June 2023 and January 2024. Console surgeons performed almost all lymphadenectomies, including the clipping of vessels. Assistant surgeons supported the lymphadenectomy using vessel sealing devices and during reconstruction. RESULTS: Thirteen patients were cStage I, one patient was cStage II, and two patients were cStage III. Distal gastrectomy, proximal gastrectomy, and total gastrectomy were performed in 11, 1, and 4 patients, respectively. D1+ and D2 lymphadenectomies were performed in 11 and 5 patients, respectively. Billroth-I, Billroth-II, Roux-en-Y, and esophagogastrostomy were performed in three, six, six, and one patients, respectively. The median operation time was 282 (245-338) min, and the median console time was 226 (185-266) min. The median blood loss was 28 (12-50) mL, and the median amylase levels in drainage fluid were 280 (148-377) U/L on postoperative day 1 and 74 (42-148) U/L on postoperative day 3. There was anastomotic leakage (Clavien-Dindo [CD] IIIa) in one patient who underwent proximal gastrectomy. The median postoperative hospital stay was 12.5 (12-14) days. CONCLUSION: In this initial case series, the hinotori™ Surgical Robot System was found to be safe and feasible for patients with gastric cancer and is suggested to be appropriate for gastrectomy, including distal gastrectomy and total gastrectomy.

Long-Term Outcomes of the Treatment for Gastric Tube Cancer After Esophagectomy for Esophageal Cancer.

BACKGROUND: The long-term outcomes of gastric tube cancer (GTC) are unclear. This study therefore aimed to clarify clinicopathologic features and the long-term outcomes of patients with GTC. METHODS: The 25 patients who were diagnosed with GTC between April 2003 and December 2022 at our hospital were eligible for inclusion in this retrospective study, and this included 27 lesions. We retrospectively evaluated clinicopathologic factors based on hospital records. RESULTS: In our cohort, 88% of incidences of GTC were located in the middle or lower gastric tube. As the treatment of GTC, we used endoscopic submucosal dissection, gastrectomy, chemoradiotherapy, chemotherapy, and best supportive care for 16 (59%), 6 (22%), 1 (4%), 1 (4%), and 3 (11%) lesions, respectively. Perforation after endoscopic submucosal dissection was observed in 6 of the 16 lesions. Partial gastric tube resection was performed for 3 patients and total gastric tube resection was performed for 3 patients. One patient who underwent total gastric tube resection died due to acute respiratory distress syndrome. In survival analysis, the 3-year overall survival rate was 52% and the 3-year disease-specific survival rate was 74%. Five patients (20%) died of aspiration pneumonia, 2 patients (8%) of another disease, and 1 patient (4%) of another type of cancer. According to multivariate analysis, independent prognostic factors for overall survival were cN status (HR, 18.021; P=0.004) and complication of aspiration pneumonia (HR, 8.373; P=0.004). CONCLUSIONS: The occurrence of aspiration pneumonia and cN status were prognostic factors after the treatment for GTC. Assessment of dysphagia and surveillance after treatment for GTC are important to improve the prognosis.

Neoadjuvant Triplet Chemotherapy with Docetaxel, Cisplatin plus 5-Fluorouracil versus Docetaxel, Cisplatin plus S-1 for Advanced Esophageal Squamous cell Carcinoma: Propensity Score Matched Analysis.

INTRODUCTION: This study examines whether neoadjuvant docetaxel, cisplatin plus S-1 (DCS) therapy is superior to docetaxel, cisplatin plus 5-fluorouracil (DCF) therapy for resectable advanced esophageal squamous cell carcinoma (ESCC). METHODS: Patients diagnosed with resectable advanced ESCC at our hospital between January 2010 and December 2019 underwent either neoadjuvant DCF therapy or DCS therapy, followed by radical esophagectomy. Prior to August 2014, we usually used neoadjuvant DCF therapy; we then completely transitioned to using neoadjuvant DCS therapy. RESULTS: A total of 144 patients received one of these triplet regimens as neoadjuvant chemotherapy: DCF therapy to 67 patients and DCS therapy to 77 patients. After propensity score matching, 55 patients in each group were selected as matched cohorts. There was no significant difference between the groups in complete response (DCF = 7.3%, DCS = 9.1%) or in partial response (DCF = 45.4%, DCS = 52.7%). The pathological response rate was 23.8% for grade 2 and 18.2% for grade 3 in the DCF group, compared with 30.9% and 14.5% in the DCS group. Independent predictive factors for recurrence-free survival were poor clinical response and pathological response ≤1b. Independent prognostic factors for overall survival were poor clinical response, anastomotic leakage, and pathological response ≤1b. Duration of hospital stays in the DCS group was significantly shorter than those of the DCF group (6.0 vs. 15.0 days, p < 0.001). Expenses of drug and hospitalization for the neoadjuvant chemotherapy in the DCS group were also significantly lower than those of the DCF group (265.7 vs. 550.3 USD, p < 0.001). CONCLUSIONS: Neoadjuvant DCS therapy for resectable advanced ESCC did not result in significantly higher clinical and pathological response than neoadjuvant DCF therapy. However, neoadjuvant DCS therapy for resectable ESCC required comparatively shorter hospital stays and incurred lower costs, making it an attractive therapeutic option.

Impact of zero anastomotic leakage after esophagectomy followed by whole stomach reconstruction for esophageal cancer: prospective cohort study.

PURPOSE: The stomach is the most common organ which is used for reconstruction after esophagectomy for esophageal cancer. It is controversial which is better narrow gastric tube reconstruction or whole stomach reconstruction to prevent anastomotic leakage. METHODS: From August 2022 to March 2023, we started a prospective cohort study of whole stomach reconstruction after esophagectomy. Until then (from January 2018 to July 2022), narrow gastric tube reconstruction was performed as a standard reconstruction. RESULTS: Narrow gastric tube reconstruction and whole stomach reconstruction were performed in 183 patients and 20 patients, respectively. The patient's characteristics were not significantly different between the narrow gastric tube group and the whole stomach group. In particular, for all patients in the whole stomach reconstruction group, retrosternal route and esophagogastrostomy by hand sewn were applied. There were no occurrences of AL through the continuous 20 cases in the whole stomach group, otherwise 42 (22.9%) patients in the narrow gastric group (P = 0.016). Postoperative hospital stays were significantly shorter in the whole stomach group than in the narrow gastric group (21 days vs. 28 days, P < .001). Blood perfusions were evaluated by indocyanine green for all cases, which had very good blood perfusion in all cases. Additionally, quantitative blood perfusion was examined by SPY-QP (Stryker, USA) for one case. Even the edge of the fornix showed more than 90% blood perfusion levels when the antrum was fixed as the reference point. CONCLUSION: Whole stomach reconstruction with excellent blood perfusion is considered to be safe and has the possibility to prevent from occurring AL after esophagectomy for esophageal cancer patients.

Impact of pulmonary vein anatomy and left atrial size on postoperative atrial fibrillation after esophagectomy for esophageal cancer.

BACKGROUND: This study aimed to investigate the relationship between postoperative atrial fibrillation (POAF) after esophagectomy and pre-existing cardiac substrate. METHODS: We retrospectively analyzed 212 consecutive patients from between July 2010 and December 2022 who were scheduled to undergo esophagectomy for esophageal cancer without previous history of atrial fibrillation. All the patients underwent both echocardiography and contrast-enhanced multi-detector computed tomography (MDCT). RESULTS: POAF occurred in 49 patients (23.1%). Multivariable logistic analysis demonstrated that independent predictors for POAF were age [OR; 1.06 (1.01-1.10), P < 0.01), three-field lymph node dissection [OR; 2.55 (1.25-5.23), P < 0.01), left atrial dilatation (> 35 mm) assessment by echocardiography [OR; 3.05 (1.49-6.25), P < 0.01) and common left pulmonary vein [OR; 3.03 (1.44-6.39), P < 0.01). The correlation coefficient was high for left atrial dimensions assessed by echocardiography and MDCT (r = 0.91, P < 0.01). Combination of left atrial dilatation by echocardiography and common left pulmonary vein had high odds ratio [OR; 8.10 (2.62-25.96), P < 0.01). Instead of echocardiographic assessment, combination of left atrial enlargement (> 35 mm) assessed by MDCT and common left pulmonary vein also showed high odds ratio for POAF [OR; 11.23 [2.19-57.63], P < 0.01). CONCLUSION: Incidence of POAF after esophagectomy was related to both left atrial enlargement and common left pulmonary vein assessed by preoperative MDCT. Additional analysis of atrial size and pulmonary vein variation would facilitate preoperative assessment of the risk of POAF, but future studies must ascertain therapeutic strategy.

Laparoscopic reconstruction in McKeown esophagectomy is a risk factor for postoperative diaphragmatic hernia.

Diaphragmatic hernia is a very rare but high-risk complication after esophagectomy. Although there are many studies on the Ivor Lewis esophagectomy procedure for diaphragmatic hernia, there are fewer studies on the McKeown procedure. The present study aimed to estimate the incidence of diaphragmatic hernia after esophagectomy, describing its presentation and management with the McKeown procedure. We retrospectively evaluated the 622 patients who underwent radical esophagectomy between January 2002 and December 2020 at the Wakayama Medical University Hospital. Statistical analyses were performed to evaluate risk factors for diaphragmatic hernia. Emergency surgery for postoperative diaphragmatic hernia was performed in nine of 622 patients (1.45%). Of these nine patients, one developed prolapse of the small intestine into the mediastinum (11.1%). The other eight patients underwent posterior mediastinal route reconstructions (88.9%), one of whom developed prolapse of the gastric conduit, and seven of whom developed transverse colon via the diaphragmatic hiatus. Laparoscopic surgery was identified in multivariate analysis as the only independent risk factor for diaphragmatic hernia (odd's ratio [OR] = 9.802, p = 0.034). In all seven cases of transverse colon prolapse into the thoracic cavity, the prolapsed organ had herniated from the left anterior part of gastric conduit. Laparoscopic surgery for esophageal cancer is a risk factor for diaphragmatic hernia. The left anterior surface of gastric conduit and diaphragmatic hiatus should be fixed firmly without compromising blood flow to the gastric conduit.

Induced pluripotent stem cell-derived dendritic cell vaccine therapy genetically modified on the ubiquitin-proteasome system.

We previously reported that dendritic cells (DCs) transduced with the full-length tumor-associated antigen (TAA) gene induced TAA-specific cytotoxic T lymphocytes (CTLs) to elicit antitumor responses. To overcome the issue of quantity and quality of DCs required for DC vaccine therapy, we focused on induced pluripotent stem cells (iPSCs) as a new tool for obtaining DCs and reported efficacy of iPSCs-derived DCs (iPSDCs). However, in clinical application of iPSDC vaccine therapy, further enhancement of the antitumor effect is necessary. In this study, we targeted mesothelin (MSLN) as a potentially useful TAA, and focused on the ubiquitin-proteasome system to enhance antigen-presenting ability of iPSDCs. The CTLs induced by iPSDCs transduced with MSLN gene (iPSDCs-MSLN) from healthy donors showed cytotoxic activity against autologous lymphoblastoid cells (LCLs) expressing MSLN (LCLs-MSLN). The CTLs induced by iPSDCs transduced ubiquitin-MSLN fusion gene exhibited higher cytotoxic activity against LCLs-MSLN than the CTLs induced by iPSDCs-MSLN. The current study was designed that peripheral T-cell tolerance to MSLN could be overcome by the immunization of genetically modified iPSDCs simultaneously expressing ubiquitin and MSLN, leading to a strong cytotoxicity against tumors endogenously expressing MSLN. Therefore, this strategy may be promising for clinical application as an effective cancer vaccine therapy.

Risk Factors for Chronic Atrial Fibrillation Development After Esophagectomy for Esophageal Cancer.

BACKGROUND: This study investigates the prognosis of patients with postoperative atrial fibrillation (POAF), aiming to elucidate predictors of occurrence of atrial fibrillation (AF) in the chronic phase after esophagectomy. METHODS: We retrospectively analyzed 415 consecutive patients between July 2010 and December 2021 who were scheduled to undergo esophagectomy for esophageal cancer and had no previous history of AF. RESULTS: POAF occurred in 73 patients (18%). Their ages were higher than those without POAF (72 [66-77] vs 68 [62-75], P < 0.01). Three-field lymph node dissection was more frequent in patients with POAF (63% vs 50%, P = 0.04). Overall survival rates were not significantly different between those with and without POAF in patients with stage III/IV cancer (P = 0.37), but overall survival rate of patients with POAF was lower than in those without POAF in stage I/II cancer (P = 0.03). Seventeen patients (4.1%) had recurrence of AF or new onset 31 days after esophagectomy. POAF was the only independent predictor of AF development in the chronic phase (HR: 4.09, 95%CI: [1.42-11.74], P = 0.01). AF development in the chronic phase was observed in 8 patients (11.0%) with and 9 patients (2.6%) without POAF (P < 0.01). AF development rates were not significantly different in patients with stage III/IV cancer (P = 0.05), but there was significant difference in patients with stage I/II cancer (P < 0.01). CONCLUSION: The occurrence of POAF after esophagectomy is related with future development of AF and overall survival prognosis. Future studies must ascertain optimal therapeutic strategy.

Risk Factors of Postoperative Intra-Abdominal Infectious Complications after Robotic Gastrectomy for Gastric Cancer.

INTRODUCTION: Robotic surgery is regarded as an evolved type of laparoscopic surgery. Few studies have undertaken detailed analysis of complications following robotic gastrectomy for gastric cancer. METHODS: This is a single-center retrospective study of 149 consecutive patients with gastric cancer who underwent robotic gastrectomy. It examines in detail the postoperative complications in robotic gastrectomy for gastric cancer, focusing on intra-abdominal infectious complications including anastomotic leakage, pancreatic fistula, and intra-abdominal abscess. We also aim to identify the related risk factors. RESULTS: The median operation time was 299 min and the median bleeding was 25 mL. The incidence of overall complications higher than grade II was 8.7%. Clinically serious complications higher than grade IIIa occurred in 6.7% of cases. The incidence of intra-abdominal infectious complications that were higher than grade II was 4.0%. Mortality in our consecutive series was zero. Multivariate logistic regression analysis indicated that postoperative intra-abdominal infectious complications were significantly associated with history of abdominal surgery (p = 0.043), with odds ratios of 17.890 (95% confidence interval 1.092-293.150) and with non-curative resection (p = 0.025), with odds ratios of 58.629 (95% confidence interval 1.687-2,037.450). DISCUSSION/CONCLUSION: Robotic gastrectomy was shown to be a safe and effective treatment for gastric cancer when performed by experienced surgeons. Attention should be paid to the risk of developing postoperative complications when performing robotic gastrectomy in gastric cancer patients with a history of abdominal surgery and in patients with advanced gastric cancer in whom there is expected to be difficulty in curative resection.

Feeding jejunostomy following esophagectomy may increase the occurrence of postoperative small bowel obstruction.

This study aimed to clarify the characteristics and treatment of bowel obstruction associated with feeding jejunostomy in patients who underwent esophagectomy for esophageal cancer. In this single-center retrospective study, 363 patients underwent esophagectomy with mediastinal lymph node dissection for esophageal cancer at the Wakayama Medical University Hospital between January 2014 and June 2021. All patients who underwent esophagectomy routinely underwent feeding jejunostomy or gastrostomy. Feeding jejunostomy was used in the cases of gastric tube reconstruction through the posterior mediastinal route or colon reconstruction, while feeding gastrostomy was used in cases of retrosternal route gastric tube reconstruction. Nasogastric feeding tubes and round ligament technique were not used. Postoperative small bowel obstruction occurred in 19 of 197 cases of posterior mediastinal route reconstruction (9.6%), but in no cases of retrosternal route reconstruction because of the feeding gastrostomy (P < .0001). Of the 19 patients who had bowel obstruction after feeding jejunostomy, 10 patients underwent reoperation (53%) and the remaining 9 patients had conservative treatment (47%). The cumulative incidence of bowel obstruction after feeding jejunostomy was 6.7% at 1 year and 8.7% at 2 years. Feeding jejunostomy following esophagectomy is a risk factor for small bowel obstruction. We recommend feeding gastrostomy inserted from the antrum to the jejunum in the cases of gastric tube reconstruction through the retrosternal route or nasogastric feeding tube in the cases of reconstruction through the posterior mediastinal route.

Nutritional benefit of remnant gastric preservation in patients with esophageal cancer undergoing radical esophagectomy and ileo-colon interposition.

BACKGROUND: This retrospective study aimed to investigate the short-term surgical outcomes and nutritional status of ileo-colon interposition in patients with esophageal cancer who could not undergo gastric tube reconstruction. METHODS: Sixty-four patients underwent subtotal esophagectomy with reconstruction using ileo-colon interposition for esophageal cancer at the Wakayama Medical University Hospital between January 2001 and July 2020. Using propensity scores to strictly balance the significant variables, we compared treatment outcomes. RESULTS: Before matching, 18 patients had cologastrostomy and 46 patients had colojejunostomy. After matching, we enrolled 34 patients (n = 17 in cologastrostomy group, n = 17 in colojejunostomy group). Median operation time in the cologastrostomy group was significantly shorter than that in the colojejunostomy group (499 min vs. 586 min; P = 0.013). Perforation of the colon graft was observed in three patients (7%) and colon graft necrosis was observed in one patient (2%) in the gastrojejunostomy group. Median body weight change 1 year after surgery in the cologastrostomy group was significantly less than that of the colojejunostomy group (92.9% vs. 88.5%; P = 0.038). Further, median serum total protein level 1 year after surgery in the cologastrostomy group was significantly higher than that of the colojejunostomy group (7.0 g/dL vs. 6.6 g/dL, P = 0.030). CONCLUSIONS: Subtotal esophagectomy with reconstruction using ileo-colon interposition is a safe and feasible procedure for the patients with esophageal cancer in whom gastric tubes cannot be used. Cologastrostomy with preservation of the remnant stomach had benefits in the surgical outcomes and the postoperative nutritional status.

Tumor RNA transfected DCs derived from iPS cells elicit cytotoxicity against cancer cells induced from colorectal cancer patients in vitro.

Significant efficacy of induced pluripotent stem cells (iPSCs) in generating DCs for cancer vaccine therapy was suggested in our previous studies. In clinical application of DC vaccine therapy, however, few DC vaccine systems have shown strong clinical response. To enhance immunogenicity in the DC vaccine, we transfected patient-derived iPSDCs with in vitro transcriptional RNA (ivtRNA), which was obtained from tumors of three patients with colorectal cancer. We investigated iPSDCs-ivtRNA which were induced by transfecting ivtRNA obtained from tumors of three colorectal cancer patients, and examined its antitumor effect. Moreover, we analyzed neoantigens expressed in colorectal cancer cells and examined whether iPSDCs-ivtRNA induced cytotoxic T lymphocytes (CTLs) against the predicted neoantigens. CTLs activated by iPSDCs-ivtRNA exhibited cytotoxic activity against the tumor spheroids in all three patients with colorectal cancer. Whole-exome sequencing revealed 1251 nonsynonymous mutations and 2155 neoantigens (IC50 < 500 nM) were predicted. For IFN-γ ELISPOT assay, these candidate neoantigens were further prioritised and 12 candidates were synthesized. IFN-γ ELISPOT assay revealed that the CTLs induced by iPSDCs-ivtRNA responded to one of the candidate neoantigens. In vitro CTLs obtained by transfecting tumor-derived RNA into iPSDCs derived from three patients with colorectal cancer showed potent tumor-specific killing effect.

Laparoscopic sleeve gastrectomy for morbid obesity improves gut microbiota balance, increases colonic mucosal-associated invariant T cells and decreases circulating regulatory T cells.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) for morbid obesity may improve gut microbiota balance and decrease chronic inflammation. This study examines the changes in gut microbiota and immune environment, including mucosal-associated invariant T cells (MAIT cells) and regulatory T cells (Treg cells) caused by LSG. METHODS: Ten morbidly obese patients underwent LSG at our institution between December 2018 and March 2020. Flow cytometry for Th1/Th2/Th17 cells, Treg cells and MAIT cells in peripheral blood and colonic mucosa and 16S rRNA analysis of gut microbiota were performed preoperatively and then 12 months postoperatively. RESULTS: Twelve months after LSG, the median percent total weight loss was 30.3% and the median percent excess weight loss was 66.9%. According to laboratory data, adiponectin increased, leptin decreased, and chronic inflammation improved after LSG. In the gut microbiota, Bacteroidetes and Fusobacteria increased after LSG, and indices of alpha diversity increased after LSG. In colonic mucosa, the frequency of MAIT cells increased after LSG. In peripheral blood, the frequency of Th1 cells and effector Treg cells decreased after LSG. CONCLUSIONS: After LSG for morbid obesity, improvement in chronic inflammation in obesity is suggested by change in the constituent bacterial species, increase in the diversity of gut microbiota, increase in MAIT cells in the colonic mucosa, and decrease in effector Treg cells in the peripheral blood.

Venous Invasion Is a Risk Factor for Recurrence of pT1 Gastric Cancer with Lymph Node Metastasis.

BACKGROUND: Postoperative adjuvant therapy for early gastric cancer (EGC) has not been widely studied, and there are differing indications for postoperative adjuvant therapy between Western and Asian countries. Japanese gastric cancer treatment guidelines do not recommend adjuvant chemotherapy for EGC, but it is unclear whether surgery alone is the most appropriate treatment. METHODS: This is a single-center retrospective study of 1001 consecutive patients who underwent radical gastrectomy for pT1 gastric cancer between 1999 and 2013 at the Wakayama Medical University Hospital. RESULTS: Recurrence was observed in 12 patients, nine of whom as the result of hematogenous metastasis. In all patients with pT1 gastric cancer (n = 1001), lymph node metastasis was identified as an independent predictive factor for recurrence (hazard ratio [HR] = 10.910, P = 0.002). In patients with pT1N + gastric cancer, however, the 5-year disease-specific survival (DSS) rate was still high, 90.8%. In patients with pT1N + gastric cancer (n = 97), the presence of venous invasion (pT1N + v +) was identified by univariate and multivariate analyses as an independent risk factor for recurrence (HR = 4.791, P = 0.032). In patients with venous invasion, the 5-year DSS rate was significantly lower than that in those without venous invasion (79.3% vs. 95.2%, P = 0.018). CONCLUSIONS: Long-term prognosis of patients with EGC with lymph node metastasis is good, but venous invasion is associated with a higher risk of recurrence. Selective application of postoperative adjuvant chemotherapy for pT1N + v + gastric cancer may efficiently improve prognosis among patients with EGC.

Pharyngolaryngectomy with thoracoscopic esophagectomy via the left thoracic approach for cervical esophageal cancer with right aortic arch: Case report.

We performed pharyngolaryngectomy with thoracoscopic esophagectomy via the left thoracic approach and reconstruction of the elongated gastric conduit with microvascular anastomosis for an 83-year-old male patient with esophageal cancer and right aortic arch. For such cases, a surgical approach via the left thoracic cavity is rational, and cases of pharyngolaryngectomy with thoracoscopic esophagectomy require a long reconstruction organ. Also, in cases of right aortic arch, a longer reconstruction route is made to avoid Kommerell's diverticulum. The patient had laryngeal cancer and was diagnosed with cervical esophageal cancer and preoperative computed tomography revealed right aortic arch. There were no complications after surgery, and food intake was good. Pharyngolaryngectomy with thoracoscopic esophagectomy via the left thoracic approach and reconstruction of the elongated gastric conduit with microvascular anastomosis is suggested to be a safe and feasible technique for cases of cervical esophageal cancer with right aortic arch.

Robotic curative para-aortic lymph node dissection via INfra-mesocolon for gastric cancer: Robotic CAVING approach.

BACKGROUND: Two major surgical complications in D2 plus para-aortic nodal dissection (PAND) for gastric cancer (GC) have been pancreatic fistula and abdominal abscess [1]. The increase in these complications is due to the excessive mobilization of the pancreas. We previously reported a laparoscopic Curative PAND Via INfra-mesocolon for GC (CAVING), which minimizes mobilization of the pancreas [2]. Robotic surgery may be more comfortable than laparoscopic surgery for the surgeon performing this CAVING approach because robotic surgery has ergonomic benefits and advantages, such as native wrist-like motion and three-dimensional vision. We initially report successful robotic CAVING approach on a 72-year-old male with GC with para-aortic nodal metastases (clinical stage IV) [3]. METHODS: We apply PAND after chemotherapy to patients with resectable gastric cancer who are suspected of having metastases to the lymph nodes around the para-aorta. CAVING approach minimizes mobilization of the pancreas and maximizes the view from the caudal side, which has been likened to cave exploration, a specialty of robotic surgery. The caudal side of the root of the superior mesenteric artery (SMA) can be dissected via the infra-pancreas, and only the cranial side of the SMA root requires a suprapancreatic approach. RESULTS: After neoadjuvant chemotherapy using trastuzumab plus S-1 and oxaliplatin, robotic subtotal gastrectomy plus D2 with PAND was performed. The operation took 491 min (105 min for PAND) with no intraoperative complications, and blood loss of 92 ml. Final pathological examination showed complete response, yp stage 0 [3]. The patient was discharged uneventfully on postoperative day 17. CONCLUSIONS: Robotic CAVING approach is feasible and safe in advanced GC with para-aortic nodal metastases, but its oncological value has yet to be determined.

Short-term Outcomes of Robotic Gastrectomy vs Laparoscopic Gastrectomy for Patients With Gastric Cancer: A Randomized Clinical Trial.

Importance: Robotic gastrectomy (RG) for gastric cancer may be associated with decreased incidence of intra-abdominal infectious complications, including pancreatic fistula, leakage, and abscess. Prospective randomized clinical trials comparing laparoscopic gastrectomy (LG) and RG are thus required. Objective: To compare the short-term surgical outcomes of RG with those of LG for patients with gastric cancer. Design, Setting, and Participants: In this phase 3, prospective superiority randomized clinical trial of RG vs LG regarding reduction of complications, 241 patients with resectable gastric cancer (clinical stages I-III) were enrolled between April 1, 2018, and October 31, 2020. Interventions: LG vs RG. Main Outcomes and Measures: The primary end point was the incidence of postoperative intra-abdominal infectious complications. Secondary end points were incidence of any complications, surgical results, postoperative courses, and oncologic outcomes. The modified intention-to-treat population excluded patients who had been randomized and met the postrandomization exclusion criteria. There was also a per-protocol population for analysis of postoperative complications. Results: This study enrolled 241 patients, with 236 patients in the modified intention-to-treat population (150 men [63.6%]; mean [SD] age, 70.8 [10.7] years). There was no significant difference in the incidence of intra-abdominal infectious complications (per-protocol population: 10 of 117 [8.5%] in the LG group vs 7 of 113 [6.2%] in the RG group). Of 241 patients, 122 were randomly assigned to the LG group, and 119 patients were randomly assigned to the RG group. Two of the 122 patients (1.6%) in the LG group converted from LG to open surgery, and 4 of 119 patients (3.4%) in the RG group converted from RG to open or laparoscopic surgery, with no significant difference. Finally, 117 patients in the LG group completed the procedure, and 113 in the RG group completed the procedure; these populations were defined as the per-protocol population. The overall incidence of postoperative complications of grade II or higher was significantly higher in the LG group (23 [19.7%]) than in the RG group (10 [8.8%]) (P = .02). Even in analysis limited to grade IIIa or higher, the complication rate was still significantly higher in the LG group (19 [16.2%]) than in the RG group (6 [5.3%]) (P = .01). Conclusions and Relevance: This study found no reduction of intra-abdominal infectious complications with RG compared with LG for gastric cancer. Trial Registration: umin.ac.jp/ctr Identifier: UMIN000031536.

Robotic Subtotal Gastrectomy with Small Remnant Stomach for Gastric Cancer in the Upper Stomach.

BACKGROUND: Robotic subtotal gastrectomy (RsTG) with a small remnant stomach for treatment of gastric cancer (GC) in the upper stomach may have advantages over robotic TG (RTG). These may affect postoperative complications and postoperative nutritional status. METHODS: This is a single-center retrospective study of 46 consecutive patients with GC who underwent RsTG (n = 10) and RTG (n = 36). The indication for RsTG included tumor located in the upper body of the stomach, in which the distance between the upper edge of the tumor and the junction was 2 cm or more and less than 5 cm, and no clinical evidence of lymph node metastasis. RESULTS: Operation time was significantly longer (384 min) and intraoperative blood loss was significantly larger (38 ml) in the RTG group than in the RsTG group (299.5 min, P = 0.021, and 25 ml P = 0.002). Two patients (5.6%) in the RTG group had complications, while no postoperative complications of higher than grade II were observed in the RsTG group. Serum albumin levels at 3 months after surgery were significantly higher in the RsTG group (3.85 g/dl) than in the RTG group (3.2 g/dl, P = 0.001). Postoperative recovery of bodyweight at 6 months after surgery was significantly better in the RsTG group (91.3%) than in the RTG group (84.25%, P = 0.001). CONCLUSION: RsTG for treatment of patients with GC in the upper body of the stomach is safe and feasible, and may enable improved postoperative nutritional status compared with RTG.

Comparison of short-term surgical outcomes using da Vinci S, Si and Xi Surgical System for robotic gastric cancer surgery.

When compared with the second/third generation da Vinci S/Si, the fourth generation Xi surgical system may allow for greater efficiency and result in shorter operation times during robotic gastrectomy (RG) for gastric cancer (GC). We directly compare surgical outcomes between the conventional S/Si and the newer Xi robotic platform for the treatment of GC. This is a single-center retrospective study of 148 consecutive patients with GC who underwent RG. Of these patients, 20 patients were treated with the S, 30 patients with the Si, and 98 patients with the Xi. The overall operation time was significantly longer in the S group (386.5 min) than in the other groups (Si group: 292 min; Xi group: 297 min) (S vs. Si: P = 0.010; S vs. Xi: P = 0.001). We observed no difference, however, between the newer Xi and Si systems in operation time. Intraoperative blood loss was similar across the three groups. The overall postoperative complication rate in the Xi group (8.2%) was lower than that of the S group (10%) and the Si group (13.3%), but the difference was not significant. The newer Xi system did not provide significant intraoperative or early postoperative advantages over the Si system.