柴崎 晋

PURPOSE: To develop an educational program that enables young surgeons to safely perform laparoscopic transabdominal preperitoneal repair (TAPP). METHODS: This retrospective study comprised 365 patients who underwent elective TAPP performed by surgical residents (SRs; n = 145 patients) and board-certified surgeons (BCSs; n = 220 patients) from January 2018 to December 2023. An educational program for SRs has been underway since April 2021 to facilitate efficient learning and ensure the safe performance of TAPP. This program comprises four steps and highlights the two points mentioned, including understanding technical principles and acquiring fundamental skills. The surgical outcomes of laparoscopic TAPP performed by SRs and BCSs were compared retrospectively. RESULTS: A total of 43 operators (16 SRs and 27 BCSs) performed the laparoscopic TAPP. The SRs demonstrated longer operative times (median 126 vs. 98 min; p < 0.01). No significant differences in the rates of seroma (7.6% vs. 5.5%), grade IIIa or higher Clavien-Dindo complications (early: 0.7 vs. 0.9%; late: 0.7% vs. 0%), and recurrence at 1 year after surgery (1.4% vs. 0.5%) were observed between the SR and BCSs groups. Following the implementation of the educational program in April 2021, laparoscopic TAPP procedures performed by SRs were associated with significantly shorter operation times compared to those conducted before the program was introduced. CONCLUSIONS: SRs who received presurgical education improved the operative time in laparoscopic TAPP, although with intraoperative guidance from Endoscopic Surgical Skill Qualification System-qualified surgeons.

PURPOSE: Reduced-port surgery has been utilized in gastric cancer surgery but is not predominantly used due to its high technical difficulty. A new single-port surgical robot named da Vinci™ SP System (DVSP) was launched and eventually approved for clinical use in Japan in November 2022. We initiated robotic gastrectomy for gastric cancer using DVSP in March 2023. Here, we report our initial experiences and assessments of the feasibility and safety of robotic gastrectomy for gastric cancer using DVSP. METHODS: This single-center retrospective study included 20 patients with gastric cancer who underwent robotic gastrectomy with DVSP from March 2023 to April 2024. The primary endpoint was the postoperative complication rate within 30 days postoperatively. Secondary endpoints were surgical outcomes, including intraoperative adverse events, operative time, blood loss, and the number of dissected nodes. RESULTS: Of the 20 patients, 6 (30.0%) were male. The median age was 74 years. Tumors in the middle to lower stomach were observed in 20 patients (100.0%), including 18 (90.0%) and 2 (10.0%) with clinical stages I and II diseases, respectively. All patients underwent distal gastrectomy. The postoperative complications of Clavien-Dindo grade ≥ II occurred in 3 (15%) patients. Intraoperative adverse events, including conversion to other approaches, were not observed. All patients underwent R0 resection. The median operative and console times were 289 and 240 min, respectively. The median blood loss was 11 mL with 50 dissected nodes. CONCLUSION: This study revealed the safe performance of robotic distal gastrectomy with standard lymphadenectomy for clinical stage I/II gastric cancer using DVSP.

BACKGROUND: Postoperative pancreatic fistula (POPF) is one of the potentially serious complications after gastrectomy for gastric cancer (GC). Drain amylase level is a predictor of POPF in open and laparoscopic gastrectomy, but no study has focused on minimally invasive surgery (MIS), including robotic gastrectomy (RG). This study assesses the effect of drain amylase levels for POPF in MIS and develop a prediction model in the MIS era. METHODS: This single-institutional retrospective study, conducted from January 2011 to December 2021, included 1,353 who underwent standard MIS for GC. We placed a drain in all patients undergoing MIS gastrectomy and measured the drain amylase level on the first postoperative day (D1Amy). The predictive accuracy of D1Amy for POPF was assessed. Additionally, the entire cohort was randomly categorized into the training (1,048 patients) and validation sets (305 patients) to establish the nomogram. RESULTS: Of the 1353 patients, 530 underwent a robotic approach. POPF and intraabdominal infectious complications of Clavien-Dindo classification grade ≥ II were observed in 80 (5.9%) and 145 (10.7%) patients, respectively. Median D1Amy was 812 U/L. The receiver operating characteristic analysis of D1Amy for POPF revealed an area under the curve (AUC) of 0.888. Multivariate analysis revealed age, tumor location, splenectomy, and D1Amy as significant risk factors for POPF. The AUC of the nomogram was 0.8960, validated with AUC of 0.9259. CONCLUSIONS: We revealed the utility of D1Amy in predicting POPF in MIS gastrectomy. Furthermore, the nomogram, incorporating D1Amy and other clinical factors, was additionally used as a predictive model for POPF.

BACKGROUND: Advanced gastric cancer with gastric outlet obstruction (GOO) causes malnutrition and medication adherence issues, leading to a poor prognosis. We developed a novel multimodal, less invasive treatment approach for gastric cancer patients with symptomatic GOO: laparoscopic stomach-partitioning gastrojejunostomy (LSPGJ) combined with neoadjuvant chemotherapy (NAC), followed by minimally invasive gastrectomy with reuse of gastrojejunostomy. This study is a retrospective analysis of the safety and feasibility of our treatment strategy. METHODS: In this single-institution retrospective study, we enrolled 54 patients (NAC group, n = 26; upfront gastrectomy group, n = 28) who achieved R0 resection through a minimally invasive approach between 2007 and 2020 and evaluated their short- and long-term outcomes. RESULTS: After LSPGJ, the Gastric Outlet Obstruction Scoring System score significantly improved (p < 0.001). The median relative dose intensity of NAC was 88.2%. Regarding short-term outcomes, there were no differences in postoperative complications, length of postsurgical hospital stay, and adjuvant chemotherapy administration. Although overall survival and relapse-free survival showed trends toward improvement in the NAC group, these differences were not statistically significant. The cumulative incidence curve for recurrence in the NAC group was significantly lower than that of the upfront gastrectomy group (p = 0.041). Recurrence and hematogenous metastasis were significantly lower in the NAC group (p = 0.031 and 0.041, respectively) than in the upfront gastrectomy group. A forest plot revealed that NAC yielded favorable outcomes, particularly for patients with a body mass index (BMI) < 18.5 kg/m2, cT4, or cN1. CONCLUSIONS: LSPGJ combined with NAC followed by minimally invasive gastrectomy was a safe and feasible treatment strategy for patients with advanced gastric cancer with symptomatic GOO. This procedure may contribute to the early recovery of oral intake and help maintain NAC dose intensity, potentially improving prognosis, particularly for patients with low BMI and advanced-stage disease.

BACKGROUND: Telesurgery has been made increasingly possible with the advancements in robotic surgical platforms and network connectivity. However, long-distance transnational complex robotic surgeries such as gastrectomy have yet to be attempted. METHODS: Multiple transnational network connections by Science Innovation Network (SINET), Japan Gigabit Network (JGN), and Arterial Research and Education Network in Asia-Pacific (ARENA-PAC) were established and tested by multiple surgeons in a dry box model. Surgeons' perceptions of the different networks were recorded. Three robotic radical D2 gastrectomies in live porcine models were performed at a hospital in Toyoake, Japan, by a surgical team in a hospital in Singapore ~5000 km away, using the hinotori Surgical Robot System (Medicaroid Corporation). RESULTS: The live porcine robotic gastrectomies were all completed in under 205 min with no intraoperative complications. From the different networks that were tested, the differences in latency ranged from 107 to 132 ms and did not translate to any significant differences in surgeon timings and perceptions. CONCLUSIONS: Transnational telesurgical radical D2 gastrectomy is feasible in a porcine model. There is no appreciable difference between surgeon performance and perception with network latencies of 107-132 ms. Long-range telesurgery as clinical practice may become possible in the future.