Efficacy of robot-assisted double-flap techniques with refinements to minimize anastomosis-related complications after proximal gastrectomy.

PURPOSE

The double-flap technique (DFT) is an anti-reflux reconstruction procedure performed after proximal gastrectomy (PG), but its complexity and high incidence of anastomotic stenosis are problematic. We conducted this study to demonstrate the efficacy of robot-assisted DFT, with refinements, to address these issues.

METHODS

Surgical outcomes were compared between the following procedures modified over time at our institution: conventional open DFT (group O, n = 16); early robotic DFT (group RE, n = 19), which follows the conventional open PG approach; and late robotic DFT (group RL, n = 21), which incorporates refinements to the early robotic DFT technique by exploiting more of the robotic capabilities available. These robotic capabilities include pre-anchoring the stomach to the diaphragmatic crus and connecting it to the esophagus, placing interrupted sutures for anastomosis, and maximally embedding the esophagus through the entire flap.

RESULTS

Anastomotic stenosis requiring balloon dilatation developed in two (11.8%) patients from group O and three (14.3%) from group RE, but not in any patients from group RL. Reflux esophagitis, classified as Los Angeles Classification grade ≥ B, decreased from 25.0% in group O to 10.5% in group RE and was completely controlled in group RL (group RL vs group O, odds ratio 0.065, 95% confidence interval < 0.001-0.684, P = 0.007).

CONCLUSION

Robotic surgery helps minimize anastomotic stenosis, while enhancing the benefits of anti-reflux reconstruction with DFT.