Background
Indocyanine green fluorescent lymphography helps visualize the lymphatic drainage pattern in gastric cancer; however, it is unknown whether fluorescent lymphography visualizes all ...metastatic lymph nodes. This study aimed to evaluate the sensitivity of fluorescent lymphography to detect metastatic lymph node stations and lymph nodes and the risk of false-negative findings.
Methods
Patients with clinical T1–4a gastric cancer were included. Indocyanine green was peritumorally injected the day prior to surgery by endoscopy. Gastrectomy with systematic D1+ or D2 lymphadenectomy was performed. Stations and lymph nodes were retrieved at the back-table using near-infrared imaging and classified as “fluorescent” or “non-fluorescent” and later matched with histopathological findings.
Results
Among 592 patients who underwent minimally invasive gastrectomy from September 2013 until December 2016, lymph node metastases were present in 150. The sensitivity of fluorescent lymphography in detecting all metastatic lymph node stations was 95.3% (143/150 patients), with a false-negative rate of 4.7% (7/150 patients) and the sensitivity in detecting all metastatic lymph nodes was 81.3% (122/150 patients). The negative predictive value was 99.3% for non-fluorescent stations and 99.2% for non-fluorescent LNs. For detecting all metastatic LN stations, subgroup analysis revealed 100% sensitivity for pT1a, 96.8% for pT1b, 100% for pT2, 91.3% for pT3, and 93.6% for pT4a tumors.
Conclusions
Fluorescent lymphography-guided lymphadenectomy can be a useful method for radical lymphadenectomy by facilitating the complete dissection of all potentially positive LN stations. Fluorescent lymphography-guided lymphadenectomy appears to be a reasonable alternative to conventional systematic lymphadenectomy for gastric cancer.
A number of different surgical techniques for the treatment of cancer of the esophagus and the esophagogastric junction have been proposed. Guidelines generally recommend a transthoracic approach for ...esophageal cancer, including Siewert type I tumors. In tumors of the proximal esophageal third, transthoracic esophagectomy may be extended to a three‐field approach, including resection of cervical lymph nodes. However, the choice between transthoracic esophagectomy with intrathoracic anastomosis (Ivor Lewis esophagectomy) and the three‐incision approach with cervical esophago‐gastrostomy (McKeown esophagectomy) remains controversial, with guidelines varying among different countries. Furthermore, it is commonly accepted that Siewert type III tumors should be treated by extended total gastrectomy with transhiatal resection of the lower esophagus, whereas currently no consensus exists regarding the optimal surgical approach for the treatment of Siewert type II adenocarcinoma. Likewise, there is a major controversy regarding palliative and potentially curative treatment modalities in oligometastatic disease. This review deals with current surgical treatment standards for cancer of the esophagus and the eosphagogastric junction, including discussion of ongoing trials.
A number of different surgical techniques for the treatment of cancer of the esophagus and the esophagogastric junction have been proposed. This review deals with current surgical treatment standards for cancer of the esophagus and the eosphagogastric junction, including discussion of ongoing trials.
Background
Robotic Roux-en-Y gastric bypass (RRYGB) is performed in an increasing number of bariatric centers worldwide. Previous studies have identified a number of demographic and clinical ...variables as predictors of postoperative complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Some authors have suggested better early postoperative outcomes after RRYGB compared to LRYGB. The objective of the present study was to assess potential predictors of early postoperative complications after RRYGB.
Methods
A retrospective analysis of two prospective databases containing patients who underwent RRYGB between 2006 and 2019 at two high volumes, accredited bariatric centers was performed. Primary outcome was rate of 30 day postoperative complications. Relevant demographic, clinical and biological variables were entered in a multivariate, logistic regression analysis to identify potential predictors.
Results
Data of 1276 patients were analyzed, including 958 female and 318 male patients. Rates of overall and severe 30 day complications were 12.5% (160/1276) and 3.9% (50/1276), respectively. Rate of 30 day reoperations was 1.6% (21/1276). The overall gastrointestinal leak rate was 0.2% (3/1276). Among various demographic, clinical and biological variables, male sex and ASA score >2 were significantly correlated with an increased risk of 30 day complication rates on multivariate analysis (OR 1.68 and 1.67, p=0.005 and 0.005, respectively).
Conclusion
This study identified male sex and ASA score >2 as independent predictors of early postoperative complications after RRYGB. These data suggest a potentially different risk profile in terms of early postoperative complications after RRYGB compared to LYRGB. The robotic approach might have a benefit for patients traditionally considered to be at higher risk of complications after LRYGB, such as those with BMI >50. The present study was however not designed to assess this hypothesis and larger, prospective studies are necessary to confirm these results.
Background
Achieving proficiency in a surgical procedure is a milestone in the career of a trainee. We introduced a competency assessment tool for laparoscopic cholecystectomy in our residency ...program. Our aim was to assess the inter-rater reliability of this tool.
Methods
We included all laparoscopic cholecystectomies performed by residents under the supervision of board certified surgeons. All residents were assessed at the end of the procedure by the supervising surgeon (live reviewer) using our competency assessment tool. Video records of the same procedure were analyzed by two independent reviewers (reviewer A and B), who were blinded to the performing trainee’s. The assessment had three parts: a laparoscopic cholecystectomy-specific assessment tool (LCAT), the objective structured assessment of technical skills (OSATS) and a 5-item visual analogue scale (VAS) to address the surgeon’s autonomy in each part of the cholecystectomy. We compared the assessment scores of the live supervising surgeon and the video reviewers.
Results
We included 15 junior residents who performed 42 laparoscopic cholecystectomies. Scoring results from live and video reviewer were comparable except for the OSATS and VAS part. The score for OSATS by the live reviewer and reviewer B were 3.68 vs. 4.26 respectively (
p
= 0.04) and for VAS (5.17 vs. 4.63 respectively (
p
= 0.03). The same difference was found between reviewers A and B with OSATS score (3.75 vs. 4.26 respectively (
p
= 0.001)) and VAS (5.56 vs. 4.63 respectively;
p
= 0.004)).
Conclusion
Our competency assessment tool for the evaluation of surgical skills specific to laparoscopic cholecystectomy has been shown to be objective and comparable in-between raters during live procedure or on video material.
Purpose
The da Vinci Surgical System family remains the most widely used surgical robotic system for laparoscopy. Data about gastric bypass surgery with the Xi Surgical System are not available yet. ...We compared Roux-en-Y gastric bypass surgery performed at our institution with the da Vinci Xi and the da Vinci Si Surgical System.
Methods
All robotic gastric bypass procedures performed between January 2013 and September 2016 were analyzed retrospectively. Patient demographics and operative and postoperative outcomes up to 30 days were compared for the da Vinci Xi and Si Surgical System. Robotic costs per procedure were modeled including posts for a standard set of robotic instruments, capital investment, and yearly maintenance.
Results
One-hundred forty-four Xi Surgical System and 195 Si Surgical System procedures were identified. Mean age (
p
= 0.9), gender distribution (
p
= 0.8), BMI (
p
= 0.6), and ASA scores (
p
> 0.5) were similar in both cohorts. Operating room times were similar in both groups (219.4 ± 58.8 vs. 227.4 ± 60.5 min for Xi vs. Si,
p
= 0.22). Docking times were significantly longer with the Xi compared with the Si Surgical System (9 ± 4.8 vs. 5.8 ± 4 min,
p
< 0.0001). There was no difference in incidence of minor (13.9 vs. 10.3%,
p
= 0.3) and major complications (5.6 vs. 5.1%,
p
= 1 for Xi vs. Si). Costs were higher for the Xi Surgical System caused by higher capital investment and yearly maintenance.
Conclusions
Roux-en-Y gastric bypass surgery can be safely performed with the Xi Surgical System, while drawbacks include longer docking times and higher costs.
Background
The purpose of this analysis is to compare the robotic EndoWrist Stapling System (EWSS) 45 mm (Intuitive Surgical Inc. Sunnyvale, CA, USA) and the ECHELON FLEX
™
ENDOPATH
®
Staplers (EFES) ...60 mm (Ethicon, Cincinnati, OH, USA) for gastric pouch formation during robotic gastric bypass surgery.
Methods
Patients who underwent robotic gastric bypass surgery with stapling using EWSS were matched with patients who underwent the same procedure with the EFES. Demographic, intra- and postoperative, and cost data were collected and analyzed.
Results
A total of 49 patients were identified who had undergone robotic gastric bypass surgery using EWSS. They were matched with 49 patients who underwent the equivalent procedure using EFES. With similar demographic parameters, corrected operating room time without cholecystectomy took longer for the patients that underwent surgery with EWSS (+22 min,
p
= 0.1042). Stapler clamping was unsuccessful in 19.0% of all recorded attempts with EWSS. Two intra-operative complications unrelated to stapling and one complication due to stapling were observed in the EWSS cohort, while none was observed for the EFES group. Significantly, more recharges were needed with EWSS to complete the gastric pouch (4.9 vs. 4.1,
p
= 0.0048) and overall stapling costs for the procedure were significantly higher (2212.2 vs. 1787.4 USD,
p
= 0.0001).
Conclusion
Gastric pouch formation using EWSS during robotic gastric bypass surgery is feasible. Due to the shorter length of EWSS compared to EFES, more stapling recharges are required to complete gastric pouch formation and the stapling costs for gastric bypass surgery are higher. Further systematic research should be conducted to precisely determine the value of the robotic EWSS for gastric bypass surgery.
Background
Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a technically demanding procedure. The learning curve of LRYGB is challenging and potentially associated with increased morbidity. This ...study evaluates whether a general laparoscopic surgeon can be safely trained in performing LRYGB in a peripheral setting, by comparing perioperative outcomes to global benchmarks and to those of a senior surgeon.
Methods
All consecutive patients undergoing primary LRYGB between January 2014 and December 2017 were operated on by a senior (A) or a trainee (B) bariatric surgeon and were prospectively included. The main outcome of interest was all-cause morbidity at 90 days. Perioperative outcomes were compared with global benchmarks pooled from 19 international high-volume centers and between surgeons A and B for their first and last 30 procedures.
Results
The 213 included patients had a mean all-cause morbidity rate at 90 days of 8% (17/213). 95.3% (203/213) of the patients were uneventfully discharged after surgery. Perioperative outcomes of surgeon B were all within the global benchmark cutoffs. Mean operative time for the first 30 procedures was significantly shorter for surgeon A compared with surgeon B, with 108.6 min (± 21.7) and 135.1 min (± 28.1) respectively and decreased significantly for the last 30 procedures to 95 min (± 33.7) and 88.8 min (± 26.9) for surgeons A and B respectively.
Conclusion
Training of a new bariatric surgeon did not increase morbidity and operative time improved for both surgeons. Perioperative outcomes within global benchmarks suggest that it may be safe to teach bariatric surgery in peripheral setting.
Introduction
Leak tests using air or methylene blue (MB) for gastrojejunal anastomoses are often performed during gastric bypass surgeries to avoid leaks due to technical errors. Still, early leaks ...have been reported in the literature. Indocyanine green (ICG) fluorescence with laser excitement makes this dye easily visible even in small amounts, and, thus, may be an excellent agent for leak testing.
Methods
During robotic gastric bypass surgery, a leak test of a gastrojejunal anastomosis was performed with air through a nasogastric tube under manual occlusion of the jejunum. Afterward, 50 ml of a mix of 100 ml sterile water, 2 mg of MB, and 5 mg ICG was injected through the same tube. The entire anastomosis was inspected for integrity under both fluorescent and normal light modes.
Results
Leak tests with air and the blend of MB and ICG have been performed in 95 patients from January 2017 to April 2018. No intraoperative leak test-related adverse events occurred. Zero (0%) patients had a positive leak test with air, 0 patients showed MB excretion, and an ICG leak was observed in four (4.2%) patients. No anastomotic complications, including leaks and/or strictures, were found 30 days postoperatively.
Conclusions
Leak tests using a blend of MB and ICG appear to be more sensitive for small defect detection of gastrojejunal anastomoses during robotic gastric bypass surgery. Larger datasets and research that is more stringent are needed to determine the exact clinical value of this new method.
Whether the benefits of the robotic platform in bariatric surgery translate into superior surgical outcomes remains unclear. The aim of this retrospective study was to establish the 'best possible' ...outcomes for robotic bariatric surgery and compare them with the established laparoscopic benchmarks.
Benchmark cut-offs were established for consecutive primary robotic bariatric surgery patients of 17 centres across four continents (13 expert centres and 4 learning phase centres) using the 75th percentile of the median outcome values until 90 days after surgery. The benchmark patients had no previous laparotomy, diabetes, sleep apnoea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI greater than 50 kg/m2, or age greater than 65 years.
A total of 9097 patients were included, who were mainly female (75.5%) and who had a mean(s.d.) age of 44.7(11.5) years and a mean(s.d.) baseline BMI of 44.6(7.7) kg/m2. In expert centres, 13.74% of the 3020 patients who underwent primary robotic Roux-en-Y gastric bypass and 5.9% of the 4078 patients who underwent primary robotic sleeve gastrectomy presented with greater than or equal to one complication within 90 postoperative days. No patient died and 1.1% of patients had adverse events related to the robotic platform. When compared with laparoscopic benchmarks, robotic Roux-en-Y gastric bypass had lower benchmark cut-offs for hospital stay, postoperative bleeding, and marginal ulceration, but the duration of the operation was 42 min longer. For most surgical outcomes, robotic sleeve gastrectomy outperformed laparoscopic sleeve gastrectomy with a comparable duration of the operation. In robotic learning phase centres, outcomes were within the established benchmarks only for low-risk robotic Roux-en-Y gastric bypass.
The newly established benchmarks suggest that robotic bariatric surgery may enhance surgical safety compared with laparoscopic bariatric surgery; however, the duration of the operation for robotic Roux-en-Y gastric bypass is longer.
Background
Multiport laparoscopy is the gold-standard approach for cholecystectomy, and single-port laparoscopy has been developed to further reduce its invasiveness. A specific robotic single-port ...platform (da Vinci single-site, Intuitive Surgical Inc., Sunnyvale, CA, USA) has been released in 2011, which could technically facilitate single-site cholecystectomy. Current data show its feasibility; however, detailed short- and long-term analyses of costs and comparisons relative to multiport laparoscopy are not available to date.
Methods
Patients who underwent robotic single-site cholecystectomy for benign, clinically noninflammatory disease between 2011 and 2015 were matched for disease, age, gender, BMI, ASA classification, diagnosis, and elapsed year of surgery to a cohort of multiport cholecystectomies. Demographic, perioperative, and long-term data were collected retrospectively and analyzed. Perioperative and long-term costs including re-operations due to the primary procedure until February 2017 were compared across both cohorts.
Results
99 patients who underwent robotic single-site cholecystectomy were matched to 99 patients with multiport cholecystectomy. A higher rate of outpatient procedures in the robotic cohort (31.3 vs. 17.2%,
p
= 0.0305) was found, and demographic parameters and perioperative clinical outcomes were similar. Perioperative costs were significantly higher for the robotic single-site patients (6158.0 vs. 4288.0 USD,
p
< 0.0001). With similar follow-up times of 59.0 and 58.9 months, respectively (
p
= 0.9552), significantly more patients of the robotic Single-Site cohort underwent follow-up surgery (7.1 vs. 0.0%,
p
= 0.0140), and follow-up costs were significantly higher for the robotic cohort (694.7 vs. 0.0 USD,
p
= 0.0145).
Conclusion
With similar early postoperative clinical results and a higher rate of re-operations, perioperative and long-term costs are significantly higher with robotic Single-Site cholecystectomy compared with multiport cholecystectomy. Considering the unclear clinical value of robotic single-site cholecystectomy and the significant short- and long-term costs, a call for further research and a debate as to who should bear the costs beyond the ones of the gold-standard treatment appear reasonable.
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