Fully robotic extended total gastrectomy with transthoracic long Roux limb reconstruction

Achieving negative margins while ensuring a safe reconstruction is known to be challenging in junctional tumors involving both the stomach and the distal esophagus. When a gastric conduit or a transhiatal Roux limb is precluded, a transthoracic long Roux limb reconstruction offers an alternative. Open approaches have traditionally carried high morbidity rates, but advances in minimally invasive surgery could possibly mitigate these limitations. The primary aim of this study was to assess the feasibility and safety of a fully robotic approach in a highly selected patient population treated in a specialized surgical setting.

All fully robotic extended total gastrectomies with transthoracic long Roux limb reconstruction performed at the ZGT Hospital in Almelo, The Netherlands, were extracted from a prospective registry. Data were summarized in tables. Means and medians were calculated as appropriate. Survival was calculated by means of Kaplan-Meier analyses.

Twenty-three patients were included, most with cT3-4N + tumors and unfavorable histology. Major complications (Clavien-Dindo ≥ 3) occurred in five (22%), and anastomotic leaks in two (8.7%) patients. Thirty- and 90-day mortality rates were 0% and 9%, respectively. Mean operative time was 7 h, with median ICU and hospital stays of 1 and 9 days, respectively. The mean lymph node yield was 26.5. There were five (22%) R1 resections, all of which had diffuse histology and intraoperative endoscopic as well as pathological assessment. The median overall and disease-free survival was 13.1 and 6.4 months, respectively.

Outcomes indicate that the technique is feasible and safe, possibly offering favorable recovery compared to traditional open methods. Oncologic outcomes are reported descriptively and should be interpreted in the context of advanced disease stage and unfavorable tumor biology. A relatively high rate of R1 resections was observed, highlighting the challenges in the represented cancer subtypes rather than procedural deficits.