Robotic distal gastrectomy using a novel pre-emptive supra-pancreatic approach without duodenal transection in the dissection of D2 lymph nodes for gastric cancer

Abstract

Background: Robot-assisted surgery has shown remarkable progress as a minimally invasive procedure for gastric cancer. This study aimed to compare the pre-emptive suprapancreatic approach without duodenal transection and the conventional approach in terms of perioperative feasibility and short-term surgical outcomes.

Methods: We retrospectively analyzed all patients who underwent robotic distal gastrectomy with D2 lymph node dissection using the da Vinci Xi robotic system between December 2021 and April 2023 and categorized them into two groups for comparison. Patients treated using the pre-emptive suprapancreatic approach (observation group) were compared with those who received the conventional approach (control group). Employing one-to-one propensity score matching, we evaluated the postoperative morbidity and short-term outcomes in these two distinct groups to assess the efficacy and safety of the novel surgical technique.

Results: This study enrolled 131 patients: 70 in the observation group and 61 in the control group. After propensity score matching, the operative times were significantly longer in the control group than in the observation group (229.10 ± 33.96 vs. 174.84 ± 18.37, p <0.001). The mean blood loss was lower in the observation group than in the control group (25.20 ± 11.18 vs. 85.00 ± 38.78, p <0.001). Additionally, the observation group exhibited a higher number of retrieved lymph nodes, including suprapyloric, perigastric, and superior pancreatic lymph nodes (28.69 ± 5.48 vs. 19.21 ± 2.89, p <0.001; 4.98 ± 1.27 vs. 4.29 ± 1.21, p = 0.012; 10.52 ± 2.39 vs. 5.50 ± 1.62, p <0.001; 6.26 ± 2.64 vs. 5.00 ± 1.72, p = 0.029). Drain amylase levels in the observation group were significantly lower than those in the control group (30.08 ± 33.74 vs. 69.14 ± 66.81, p <0.001).

Conclusion: This study revealed that using the pre-emptive suprapancreatic approach without duodenal transection in the dissection of D2 lymph nodes for gastric cancer is a safe and feasible procedure in terms of surgical outcomes.

Keywords: gastric cancer; gastrointestinal surgery; lymph node dissection; pre-emptive supra-pancreatic approach; robotic distal gastrectomy.

Figure 1

Preemptive supra-pancreatic approach without duodenal transection. ① Schematic diagram of the novel approach. ② Tumor localization. ③ Dissection of suprapyloric lymph nodes. ④\⑤ Dissection of superior pancreatic lymph nodes. ⑥ Dissection of NO.4sb lymph nodes. ⑦ Dissection of Subpyloric lymph nodes. ⑧ Billroth II gastrojejunal anastomosis.

Figure 2

Cumulative survival curves for patients undergoing preemptive suprapancreatic approach without duodenal transection and the conventional approach after propensity score matching. The 1-year overall survival rate did not differ significantly between the observation and control groups (97.8% vs.95.6%, respectively; log-rank p = 0.543).