Da Vinci robot-assisted pylorus- and vagus nerve-preserving gastrectomy for early gastric cancer: A single-center study

Da Vinci robot-assisted pylorus- and vagus nerve-preserving gastrectomy for early gastric cancer: A single-center study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Da Vinci robot-assisted pylorus- and vagus nerve-preserving gastrectomy for early gastric cancer: A single-center study Yichuan Fan, Maohua Wei, Chi Zhang, Pin Liang, Xiang Hu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1961065/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This study aimed to assess the efficacy, feasibility, and safety of robot-assisted pylorus- and vagus nerve-preserving gastroplasty (RA[PPG]), using the da Vinci Surgical System, compared with those of laparoscopy-assisted PPG (LAPPG). Methods Clinical and follow-up data of patients who underwent PPG were retrospectively analyzed, which included 14 RAPPG and 21 LAPPG cases. The histological data, surgical results, postoperative recovery, and complication rates were compared between the two groups; the surgical experience was also summarized. Results The operation time was slightly longer in the RAPPG group (309.3 ± 59.9 vs. 236.2 ± 36.5 min, P < 0.05), but this group had less intraoperative bleeding. The length of the preserved pyloric canal, number of dissected lymph nodes, postoperative recovery, and overall complication rates were not significantly different. The proportion of delayed gastric emptying and acid reflux symptoms in the LAPPG group was slightly greater than that in the RAPPG group. Conclusion The da Vinci Surgical System is a safe and feasible way to control the postoperative gastric emptying speed and to effectively reduce reflux. robotic surgery gastric cancer vagus nerve pylorus gastrectomy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction China has one of the highest occurrences of gastric cancer (GC) throughout the world, and with the increasing popularity of physical examination, the incidence of early gastric cancer (EGC) has been rising each year[ 1 ]. The lymph node metastasis rate of EGC is relatively low, and the prognosis is relatively good. The standard treatment method for EGC has developed gradually to prioritize reduction, minimal invasiveness, individualization, and precision or a combination of these four aspects. In particular, function-preserving surgery for GC has been gaining increasing attention. The surgical safety and oncological prognosis of partial gastrectomy (pylorus-preserving gastrectomy [PPG]) for EGC are comparable to those of distal gastrectomy[ 2 , 3 ]. However, partial gastrectomy has the advantages of reducing the incidence of dumping syndrome, bile reflux gastroesophagitis, cholelithiasis, and nutritional deficiency over distal gastric surgery. The updated 6th edition of the Japanese Gastric Treatment Guidelines in 2021 also emphasizes PPG as a surgical method for early- to mid-gastric cancer with cT1N0, > 4 cm distal to the pylorus[ 4 ]. However, the major complications of PPG, such as delayed duodenal discharge, residual gastric food, postprandial nausea, or upper fullness, are the greatest concerns of surgeons[ 5 ]. Mutual interference between instruments, termed the "chopstick effect,” increases operation difficulty, prolongs the learning curve, and reduces the safety of the operation. The "chopstick effect” and the “straight-line effect” of laparoscopic surgery limit the refinement of the operation. The da Vinci robotic surgery system has been widely adopted in the surgical field due to its many advantages, such as a high-resolution, enlarged three-dimensional (3D) visual field, stability, and flexibility. Researchers have confirmed that robotic systems are safe and feasible for the surgical treatment of GC[ 6 , 7 ]. The Chinese expert consensus on intracorporeal digestive reconstruction after robotic gastrectomy (2021 edition) recommends robot-assisted partial gastrectomy with pylorus preservation[ 8 ]. The Department of Gastrointestinal Surgery of the First Affiliated Hospital of Dalian Medical University has extensive experience in PPG. The department has carried out considerable clinical work on open and laparoscopy-assisted PPG (LAPPG) treatment for EGC, forming a complete technical and theoretical system. The robotic da Vinci Surgical System was introduced to our hospital as part of the movement toward minimally invasive technology. Our team carried out robot-assisted pylorus and vagus-preserving gastrectomy (RAPPG), assisted by the da Vinci Surgical System, and preliminarily evaluated its safety and feasibility[ 9 ]. The intraoperative and postoperative conditions, complications, and efficacies of RAPPG and LAPPG were simultaneously analyzed and compared. Data And Methods I. Research participants Using a retrospective analysis, 14 patients who underwent RAPPG surgery (control group) and 21 patients who underwent LAPPG surgery (LAPPG group) during the same period at the First Affiliated Hospital of Dalian Medical University between December 2020 and January 2021 were included. When basic clinical data (sex, age, BMI, and preoperative ASA score) of the two groups were compared, no differences were found (Table 1 ). Tumor location and the presence of distant metastases were determined using computed tomography (CT) and endoscopy prior to surgery. All operations were performed by the same surgical and nursing teams. Samples were processed based on the 15th edition of the Japanese Classification of Gastric Carcinoma (JCGC)[ 10 ], and tumor, node, and metastasis (TNM) as well as pathological stages were confirmed according to the 8th edition of the American Joint Committee of Cancer (AJCC) guidelines[ 11 ]. II. Operative method The scope of surgical resection and lymph node dissection was in accordance with the Japanese Gastric Cancer Treatment Guidelines. RAPPG was performed with the patient in the supine position at 15 o , with the head high and feet low and an assistant on the right side of the patient. After the procedure, the trocar setting was optimized to adopt the "U"-shaped layout to avoid a collision with the robotic arm (Fig. 1 ). There are two common key technical links between RAPPG and traditional PPG: (1) no. 6 lymph node dissection with preservation of the subpyloric vessels and (2) management of the upper edge of the pancreas with preservation of the coeliac branch of the vagus nerve. However, since the "immersive" 3D stereo imaging system of the da Vinci Surgical System can provide a field of view similar to that of open surgery, the movements between the surgeon's control platform and the robotic arm are highly synchronized, and the surgeon can control both the lens and machine simultaneously. This reduces the coordination error with other operators and avoids the "straight-line effect" of laparoscopic surgery. This distinction differentiates RAPPG from LAPPG. (1) No. 6 lymph node dissection with preservation of subpyloric vessels Preserving the vessels around the pylorus can maintain the basic shape of the pylorus and has little effect on the function of the pylorus after PPG. Our team preserved both the inferior pyloric vein and inferior pyloric plexus. Prevention of postoperative pyloric spasm and edema can effectively preserve the gastric emptying function; therefore, it is best to maintain the length of the pyloric canal at 3–4 cm. In principle, the hepatic and pyloric branches of the anterior vagus were preserved. Moreover, the celiac branch of the vagus was preserved as much as possible. The bifurcation of the right gastroepiploic vessel and the inferior pyloric vessel was considered the center, dissociating and exposing from the upper, lower, right, and left directions, as well as from the ventral and dorsal sides to complete the dissection of the subpyloric lymph nodes. First, the lymph nodes in the subpyloric region were dissected along the front of the pancreatic head from the right side. Then, the omentum was opened in the avascular region between the subpyloric vessel and the first branch of the right gastroepiploic vessel, which communicated with the left free plane, and they were each cut off from the gastric wall along the right gastroepiploic vessel branches. The greater curvature of the gastric antrum was exposed 4–5 cm for amputation and anastomosis. The lymph nodes were dissected downward from the pylorus and duodenum to the bifurcation of the inferior pyloric vessel and the right gastroepiploic vessel. Second, the lymph nodes were dissected from the bottom along the root of the right gastroepiploic vein to the top of the bifurcation. Finally, from the left side of the pancreas, the lymph nodes were dissected along the vessels to the bifurcation, and 4–5 cm of the right gastroepiploic vessels were circumscribed from the bifurcation as the starting point to complete the subpyloric lymph node dissection. The inferior pyloric artery and vein were preserved together, and the distal end of the right gastroepiploic vessel was clipped and severed by hemo-lock near the bifurcation (Fig. 2 ). (2) Protection of the vagus The vagus was exposed from the right side of the gastric pancreas. When dissecting the exposed nerve, the output power of the device could be appropriately reduced to avoid burns to the nerve tissue using the energy platform. During the operation, a combination of the right diaphragmatic crus approach, left retroperitoneal approach, and esophageal approach was used to anatomically observe the distribution of the posterior vagus nerve and its branches and to determine the anatomical type of the left gastric vessel. Using the nerve fibers surrounding the artery as a landmark, lymph node dissection outside the nerve fiber membrane was the technical core of this link. Arm 4 used grasping forceps to lift the descending branch arch of the left gastric vessel and omental fat tissue together and pull them to the abdominal wall. It can also pull to the left and right sides of the surgical field to facilitate exposure and operation of the surgical field. Here, the assistant carried a piece of gauze to hide the tip of the clamp, pressed the lower one-third of the body of the pancreas, pulled the pancreas to the side of the foot, turned the upper edge of the pancreas outward, and pulled the pancreas to the left and right sides with surgical field transformation. Assistant forceps are usually located outside the surgical field and handled carefully to avoid damage to the pancreas, mesenteric vessels, superior mesenteric vessels, and bowel. Arm 3 used bipolar electrocoagulation or electric scissors to facilitate lymph node dissection and nerve exposure at the upper edge of the pancreas. Arm 1 used grasping forceps to assist with retraction and exposure (Fig. 3 ). (3) Treatment of the gastric left vessel and cardia esophageal branch Retention of the cardia esophageal branch plays an important role in maintaining the morphology and function of the cardia. To maintain its structural integrity, the esophageal hiatus should not be destroyed or opened too much during the procedure (Fig. 4 ). The right-sided approach was used to expose the anterior wall of the lesser curvature below the cardia and to determine the esophagocardial branch of the left gastric vessel. Maintaining the shape of the stomach after anastomosis depends on the survival of this branch. At the distal end of the branch, lymph nodes 1 and 3 were cleared along the lesser curvature of the gastric wall and right branch of the diaphragmatic crus. The distal part of the stomach was dissociated from the lower part of the cardia, exposing the bifurcation of the esophagus-cardia branch of the left gastric vessel and the whole proximal to the descending branch of the left gastric vessel (Fig. 5 ). A 10-cm midline incision was made in the upper abdomen to lift the stomach, and titanium clips marked under the preoperative endoscope were searched to determine the location of the tumor. To ensure sufficient incision margins, we used in vitro manual gastro-stomach anastomosis (the suture method adopts continuous full-thickness or discontinuous full-thickness sutures) and interrupted the seromuscular embedding suture. III. Index analysis and follow-up study The clinicopathological data, surgical status, postoperative complications, postoperative recovery schedule time, feeding time, and postoperative hospital stay of both groups were recorded. Telephone and outpatient follow-up were used to record patient survival status and tumor recurrence. Following surgery, patients were monitored every three months for two years and every six months for the next three to four years after the surgery. This study was conducted until January 2022. IV. Statistical methods Data were analyzed using SPSS 21.0, and descriptive statistics were expressed as mean ± standard deviation (SD) or as percentages. Data from the measurement and count were compared using the independent sample t-test and the Chi-square test, respectively. Postoperative survival was calculated using the Kaplan-Meier method, and survival was compared using the log-rank test. Statistical significance was set at P < 0.05. Results Both the RAPPG and LAPPG groups underwent successful operations, and neither group was converted to open surgery. Tumor size (2.5 ± 0.8 vs. 2.9 ± 1.2 cm, P = 0.257), depth of invasion, histological type, and stage distribution were similar between the two groups, and the mean distal and proximal resection margins were > 2 cm in both groups (Table 2 ). The length of the preserved pyloric canal was > 2 cm (3.9 ± 1.0 vs. 3.6 ± 0.6 cm, P = 0.873). The average number of detected lymph nodes in the RAPPG group was slightly higher than that in the LAPPG group (26.1 ± 9.8 vs. 17.7 ± 8.6, P = 0.068), but the difference was not statistically significant. There was no difference in the mean number of positive lymph nodes (0.3 ± 1.0 vs. 0.2 ± 0.7, P = 0.734) (Table 2 ). The RAPPG group took longer to operate than the LAPPG group (309.3 ± 59.9 vs. 236.2 ± 36.5 min, P < 0.05), but the blood loss was significantly less than that in the LAPPG group (39.3 ± 31.2 vs. 48.5 ± 33.6 mL, P < 0.05) (Table 3 ). The postoperative exhaust time, liquid food intake, and drainage tube removal time in the RAPPG group were slightly shorter than those in the LAPPG group, and the differences were statistically significant. The time to discharge was approximately the same in each group, and both groups experienced the same frequency of perioperative complications. Based on the monitoring of the laboratory test indicators of patients during the perioperative period, four patients from the RAPPG group and nine patients from the LAPPG group developed hyperamylase after surgery; all of these patients were successfully treated with intravenous somatostatin. No serious complications occurred, and amylase levels in blood were the same in both groups on the first and third postoperative days (Fig. 6 a). Compared with the RAPPG group, the LAPPG group had a higher leukocyte count on the first postoperative day. After postoperative prophylactic antibiotic treatment, there was no significant difference in the WBC count between the two groups on the third postoperative day (Fig. 6 b). On the first day after surgery, hemoglobin levels in the LAPPG group were somewhat higher than those in the RAPPG group. On the third postoperative day, the overall hemoglobin levels of the two groups decreased slightly with no statistical difference between the groups (Fig. 6 c). During the follow-up period, gastric emptying was delayed in one (7.1%) RAPPG patient and four (19.0%) LAPPG patients; moreover, the symptoms of these patients improved with conservative treatment. RAPPG and LAPPG participants were followed up on average for 9.3 months and 16.4 months, respectively. No recurrence occurred during the follow-up periods. None of the patients received adjuvant chemotherapy after surgery, and none of the patients in either group died (Table 3 ). Outpatient follow-up was performed every three months for two years after the operation. The anastomotic stoma healed well in most patients with gastroscopy three months after the operation, and anastomotic stomatitis was occasionally observed (Fig. 7 a). The patients were given dietary guidance and acid suppression was added if necessary; anastomotic stomatitis was mostly relieved at six to nine months after the operation (Fig. 7 b). Upper gastrointestinal angiography revealed good pyloric systolic function and gastric emptying (Figs. 7 c- 7 d). Discussion Minimally invasive surgery for GC has been widely used clinically to improve outcomes in patients undergoing gastrectomy. Postoperative benefits include reduced pain, lower risk of complications, decreased blood loss, shorter hospital stays, and earlier return to normal activities. Since its introduction in the late 1990s, the robotic surgical system has provided a breakthrough in the minimally invasive treatment of GC. The robotic surgical system is more suitable for abdominal surgery in some special areas, such as proximal gastrectomy, procedures related to the hepatic curvature of the colon, splenic resection, and low rectal resection. Robotic surgical systems are excellent for long-term, delicate, and complicated abdominal operations, such as function-preserving surgery (PPG, distal gastrectomy with vagus nerve preservation, and lateral lymph node clearance), pancreaticoduodenectomy, complex liver and biliary surgery, and vascular anastomosis; their main advantages are that they filter tremors, they have multi-dimensional motor mechanical arms, they allow deep regional lymph node dissection, and they provide tissue and organ protection during lymph node dissection[ 7 , 12 ]. The detection rate of EGC has gradually improved with the popularization of GC screening and endoscopic diagnosis. Function-preserving surgery has become a major strategy for improving the quality of life of patients after gastrectomy for EGC. In recent years, PPG, known as the Maki surgery, has been widely used for the treatment of EGC (cT1N0M0) located in the middle part of stomach and the distal edge from the pylorus (> 4 cm). This specific placement ensures that the distal end of the tumor is 2 cm away from the lower resection margin and the lower resection margin is ≥ 2 cm away from the pyloric canal to reduce the scope of gastrectomy. Preserving the pylorus and vagus nerves can significantly improve the quality of life of patients after surgery and reduce the incidence of postoperative dumping syndrome, bile reflux, and cholelithiasis; moreover, the oncological results are satisfactory[ 13 ]. RAPPG combines a minimally invasive concept and functional retention with the advantages of minimal invasiveness and early postoperative rehabilitation; however, there are few reports on RAPPG surgery. Hashizume first reported that the da Vinci Surgical System was used for the treatment of GC and achieved good results[ 14 ]. Several studies have shown the safety and feasibility of da Vinci robotic surgery for the treatment of GC. Our department has summarized its previous experience with da Vinci robotic surgery and believes that da Vinci RAPPG is safe and feasible[ 9 ]. The primary purpose of PPG surgery is to preserve the gastric function, namely the emptying and anti-reflux functions. More effective and accurate preservation of the vagal nerve branch, subpyloral vessels, and left gastric vessels is the key focus of surgical success, and the da Vinci Surgical System undoubtedly provides more favorable conditions for surgeons. Recent studies on robotic gastrectomy for GC suggest that robotic surgical outcomes are superior to the outcomes of laparoscopic surgery, especially in terms of perioperative blood loss, surgery-related morbidity of postoperative complications, and length of hospital stay[ 15 , 16 ]. Our team’s study also suggests that the bleeding amount of the da Vinci surgery group was less than that of the laparoscopic group. While there were benefits from the improved field of vision and stable operation, there were also benefits from the energy platform, as the team routinely used the Arm 1 bipolar electrocoagulation and Arm 3 electrical scissors, which quickly and effectively achieved hemostasis. The postoperative exhaust and diet recovery time in the RAPPG group was better than that in the LAPPG group, and the average postoperative hospital stay was 1.1 days shorter in the RAPPG group than that in the LAPPG group. However, the time and cost of robotic surgery are consistent with its application; both were higher than those in the LAPPG group[ 17 ]. A long operation time is one of the factors that limits the development of robotic surgery and may be overcome with extensive operative experience. In addition, robotic surgery is not included in medical insurance in China, and its cost is approximately 15,000–30,000 RMB higher than that of laparoscopic surgery, which is also one of the lagging factors for its widespread development. Finally, related studies revealed that the detection rate of lymph nodes in the robotic surgery system was higher, and more lymph nodes were detected in the upper pancreatic area (groups 7-12a) (14.5 vs 11.3, P = 0.023) in our study[ 18 – 20 ]. However, more clinical data are needed for validation. Even though the average number of lymph nodes detected in the RAPPG group was slightly higher than that in the LAPPG group, the difference was not statistically significant. In addition, we routinely marked a metal titanium clip at the proximal end of the tumor through endoscopy before surgery and combined this technique with upper gastrointestinal angiography to determine the location of the tumor and formulate the scope of surgical resection. We sometimes combined it with magnifying endoscopy to determine the size and boundary of the tumor. By touching these metal clips during surgery, the extent of the gastrectomy could be determined. Intraoperative frozen pathology to confirm negative proximal and distal margins was required. Conclusion The overall effect of RAPPG surgery was satisfactory. It effectively overcame the "chopstick effect” and "straight-line effect” of laparoscopic surgery and had a field of view and free adjustment similar to those of open surgery. The learning curve was shorter for surgeons with experience in open surgery. Our department could independently perform intraoperative gastroscopy. Using robotic technology, surgeons can achieve real-time dynamic navigation, accurately locate the lesion, and complete more precise operations to ensure accurate and complete resection of EGC. In summary, robotic radical gastrectomy still has many advantages over ordinary laparoscopic surgery, including the learning curve, controlling blood loss, surgical precision, and quick recovery. The treatment of EGC can achieve a satisfactory prognosis and can effectively control surgical risk and postoperative complications. Moreover, while achieving the purpose of radical resection, the concept of minimally invasive surgery may be better utilized, and the quality of life of patients after surgery can be improved. With a future series of prospective multicenter clinical studies, various robotic surgical methods may be standardized, and we believe that this application of minimally invasive technology in the treatment of GC will broaden. Abbreviations GC: gastric cancer; EGC: early gastric cancer; PPG: pylorus-preserving gastrectomy; LAPPG: pylorus and vagus-preserving gastrectomy; RAPPG: robot-assisted pylorus and vagus-preserving gastrectomy Declarations Acknowledgements None. Authors’ contributions X.H. designed the study; C.F.and H.W. were co-first authors and contributed maximally and equally to the study; C.F. and H.W. collected and analyzed the data; C.Z. and X.H interpreted the data; C.F. drafted the manuscript; P.L. and X.H. revised the manuscript. The authors read and approved the final manuscript. Funding None. Availability of data and materials All experimental data used to support these findings are included in the article. Ethics approval and consent to participate This study was approved by the Institutional Review Board of the First Affiliated Hospital of Dalian Medical University. Written informed consent for publication was obtained from all patients. Consent for publication Written informed consent was obtained from the patients and legal guardian for the publication of these patients. Competing interests The authors declare that they have no conflicts of interest. References Wang FH, Zhang XT, Li YF, Tang L, Qu XJ, Ying JE, Zhang J, Sun LY, Lin RB, Qiu H, et al: The Chinese Society of Clinical Oncology (CSCO): Clinical guidelines for the diagnosis and treatment of gastric cancer, 2021 . Cancer Commun (Lond) 2021, 41 :747–795. Zhou J, Du R, Zhang Q, Wang D: Laparoscopy-assisted pylorus-preserving gastrectomy versus laparoscopy-assisted distal gastrectomy for early gastric cancer in perioperative outcomes: A meta-analysis . Asian J Surg 2020, 43 :862–863. Oh SY, Lee HJ, Yang HK: Pylorus-Preserving Gastrectomy for Gastric Cancer . J Gastric Cancer 2016, 16 :63–71. AJGC: Japanese Gastric Cancer Treatment Guidelines . 6th . Berlin, Germany: Springer 2021. 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Alhossaini RM, Altamran AA, Cho M, Roh CK, Seo WJ, Choi S, Son T, Kim HI, Hyung WJ: Lower rate of conversion using robotic-assisted surgery compared to laparoscopy in completion total gastrectomy for remnant gastric cancer . Surg Endosc 2020, 34 :847–852. Marano L, Fusario D, Savelli V, Verre L, Neri A, Marrelli D, Roviello F: Robotic versus laparoscopic gastrectomy for gastric cancer: protocol for umbrella review of systematic reviews and meta-analyses . BMJ Open 2020, 10 :e033634. Isobe T, Murakami N, Minami T, Tanaka Y, Kaku H, Umetani Y, Kizaki J, Aoyagi K, Fujita F, Akagi Y: Robotic versus laparoscopic distal gastrectomy in patients with gastric cancer: a propensity score-matched analysis . BMC Surg 2021, 21 :203. Chen K, Pan Y, Zhang B, Maher H, Wang XF, Cai XJ: Robotic versus laparoscopic Gastrectomy for gastric cancer: a systematic review and updated meta-analysis . BMC Surg 2017, 17 :93. Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files table1.tif table2.tif table3.tif Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1961065","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":129432159,"identity":"191e50d8-67b2-46bc-b0e8-1cfd2e125df4","order_by":0,"name":"Yichuan Fan","email":"","orcid":"","institution":"First Affiliated Hospital of Dalian Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yichuan","middleName":"","lastName":"Fan","suffix":""},{"id":129432160,"identity":"bdea40b6-5d2a-490e-87d1-bbaf0e50764e","order_by":1,"name":"Maohua Wei","email":"","orcid":"","institution":"First Affiliated Hospital of 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Hu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAApElEQVRIiWNgGAWjYBACAyCWYGCw4eFnbyBNS5qMZM8B0rQctjG44UCkFnOJHMNbN9vO8zDcYGD88DGHCC2WM9KSrXPbbvMwzm5glpy5jRiH3Ug+Jg3SwixzgI2ZlzgtiW1ALed42CQSiNYCtuUADw/xWs48S7bOOZfMI8FzsJlIvxzPMbydU2Znb3+8+eCHj8RoQQKMDaSpHwWjYBSMglGAGwAAm9kzt4dKf4oAAAAASUVORK5CYII=","orcid":"","institution":"First Affiliated Hospital of Dalian Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Xiang","middleName":"","lastName":"Hu","suffix":""}],"badges":[],"createdAt":"2022-08-14 12:14:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1961065/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1961065/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":25430456,"identity":"993704c2-589d-42dc-8360-3d63cb3eb84e","added_by":"auto","created_at":"2022-08-19 17:39:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":107192,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTrocar layout in robot-assisted PPG\u003cspan class=\"ql-cursor\"\u003e\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"fig1trocar.png","url":"https://assets-eu.researchsquare.com/files/rs-1961065/v1/f2270e3bc2ab36a76d50a366.png"},{"id":25430464,"identity":"9ea846a3-5c58-4b9a-b77a-375530ff35d9","added_by":"auto","created_at":"2022-08-19 17:39:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2013953,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eManagement of the inferior pyloric area\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-1961065/v1/4f973b4dfa07f260dca1730a.png"},{"id":25432213,"identity":"3f270744-7fba-4033-9edf-6ee01935029a","added_by":"auto","created_at":"2022-08-19 17:49:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2739184,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eManagement of the vagus\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-1961065/v1/69ae0d3fa14ca9fcca03a0ea.png"},{"id":25430458,"identity":"2f3fb83e-02ed-4e96-bdfa-de89c0b63f38","added_by":"auto","created_at":"2022-08-19 17:39:45","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":2520962,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eManagement of the esophageal hiatus\u003cspan class=\"ql-cursor\"\u003e\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-1961065/v1/8fb831ea2e4b2d03a7d202c0.png"},{"id":25431073,"identity":"64d65192-96f0-4b30-a5e9-2365616f48ee","added_by":"auto","created_at":"2022-08-19 17:44:45","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2871892,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eManagement of the left gastric esophageal-cardia branch\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"fig5.png","url":"https://assets-eu.researchsquare.com/files/rs-1961065/v1/393ec4ddf553a374c8d276f8.png"},{"id":25430462,"identity":"0577a479-afd8-4d70-9890-e9a6f7f7a899","added_by":"auto","created_at":"2022-08-19 17:39:45","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":63780,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePerioperative laboratory examination.\u003c/strong\u003e (a) Hemodiastase level on D1 and D3 after surgery. (b) Leucocyte level on D1 and D3 after surgery (* p \u0026lt;0.05). (c) Hemoglobin level on D1 and D3 after surgery.\u003c/p\u003e","description":"","filename":"Fig6.png","url":"https://assets-eu.researchsquare.com/files/rs-1961065/v1/d2fecbd438318b0ec6dfb7a7.png"},{"id":25431072,"identity":"c1a97318-2cb8-48df-a00f-1b6be8ee42d0","added_by":"auto","created_at":"2022-08-19 17:44:45","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":672344,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGastroscopy and upper gastrointestinal angiography\u003c/strong\u003e \u003cstrong\u003eafter surgery\u003c/strong\u003e. (a) Gastroscopy at 3 months after surgery. (b) Gastroscopy at 6 months after surgery. (c) Upper gastrointestinal tract angiography at 3 months after surgery. (d) Upper gastrointestinal tract angiography at 6 months after surgery.\u003c/p\u003e","description":"","filename":"fig7.png","url":"https://assets-eu.researchsquare.com/files/rs-1961065/v1/3be3ad70abd0471affd1c512.png"},{"id":26566793,"identity":"4c31110d-6813-44ed-82ff-4f9ca63791cf","added_by":"auto","created_at":"2022-09-16 16:14:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":9961659,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1961065/v1/a2de76c7-128f-4195-adb8-6ea12ab0c262.pdf"},{"id":25431071,"identity":"11cb28f0-1d9c-4089-ba4f-863e53f12b1d","added_by":"auto","created_at":"2022-08-19 17:44:45","extension":"tif","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":327864,"visible":true,"origin":"","legend":"","description":"","filename":"table1.tif","url":"https://assets-eu.researchsquare.com/files/rs-1961065/v1/17f5f5ff6d7e9bb69677b210.tif"},{"id":25431068,"identity":"976f21bc-b0b9-416b-b6c2-b189777d231c","added_by":"auto","created_at":"2022-08-19 17:44:45","extension":"tif","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":92300,"visible":true,"origin":"","legend":"","description":"","filename":"table2.tif","url":"https://assets-eu.researchsquare.com/files/rs-1961065/v1/866ff7c6019c613cc9e64c2e.tif"},{"id":25431069,"identity":"f7f4489a-92ca-46e1-a5df-c8ce12ed30f0","added_by":"auto","created_at":"2022-08-19 17:44:45","extension":"tif","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":93784,"visible":true,"origin":"","legend":"","description":"","filename":"table3.tif","url":"https://assets-eu.researchsquare.com/files/rs-1961065/v1/a0155612fe02f5617f3c51dc.tif"}],"financialInterests":"No competing interests reported.","formattedTitle":"Da Vinci robot-assisted pylorus- and vagus nerve-preserving gastrectomy for early gastric cancer: A single-center study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChina has one of the highest occurrences of gastric cancer (GC) throughout the world, and with the increasing popularity of physical examination, the incidence of early gastric cancer (EGC) has been rising each year[\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]. The lymph node metastasis rate of EGC is relatively low, and the prognosis is relatively good. The standard treatment method for EGC has developed gradually to prioritize reduction, minimal invasiveness, individualization, and precision or a combination of these four aspects. In particular, function-preserving surgery for GC has been gaining increasing attention. The surgical safety and oncological prognosis of partial gastrectomy (pylorus-preserving gastrectomy [PPG]) for EGC are comparable to those of distal gastrectomy[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, partial gastrectomy has the advantages of reducing the incidence of dumping syndrome, bile reflux gastroesophagitis, cholelithiasis, and nutritional deficiency over distal gastric surgery. The updated 6th edition of the Japanese Gastric Treatment Guidelines in 2021 also emphasizes PPG as a surgical method for early- to mid-gastric cancer with cT1N0, \u0026gt;\u0026thinsp;4 cm distal to the pylorus[\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eHowever, the major complications of PPG, such as delayed duodenal discharge, residual gastric food, postprandial nausea, or upper fullness, are the greatest concerns of surgeons[\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]. Mutual interference between instruments, termed the \"chopstick effect,\u0026rdquo; increases operation difficulty, prolongs the learning curve, and reduces the safety of the operation. The \"chopstick effect\u0026rdquo; and the \u0026ldquo;straight-line effect\u0026rdquo; of laparoscopic surgery limit the refinement of the operation. The da Vinci robotic surgery system has been widely adopted in the surgical field due to its many advantages, such as a high-resolution, enlarged three-dimensional (3D) visual field, stability, and flexibility. Researchers have confirmed that robotic systems are safe and feasible for the surgical treatment of GC[\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]. The Chinese expert consensus on intracorporeal digestive reconstruction after robotic gastrectomy (2021 edition) recommends robot-assisted partial gastrectomy with pylorus preservation[\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe Department of Gastrointestinal Surgery of the First Affiliated Hospital of Dalian Medical University has extensive experience in PPG. The department has carried out considerable clinical work on open and laparoscopy-assisted PPG (LAPPG) treatment for EGC, forming a complete technical and theoretical system. The robotic da Vinci Surgical System was introduced to our hospital as part of the movement toward minimally invasive technology. Our team carried out robot-assisted pylorus and vagus-preserving gastrectomy (RAPPG), assisted by the da Vinci Surgical System, and preliminarily evaluated its safety and feasibility[\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. The intraoperative and postoperative conditions, complications, and efficacies of RAPPG and LAPPG were simultaneously analyzed and compared.\u003c/p\u003e"},{"header":"Data And Methods","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\n\u003ch2\u003eI. Research participants\u003c/h2\u003e\n\u003cp\u003eUsing a retrospective analysis, 14 patients who underwent RAPPG surgery (control group) and 21 patients who underwent LAPPG surgery (LAPPG group) during the same period at the First Affiliated Hospital of Dalian Medical University between December 2020 and January 2021 were included. When basic clinical data (sex, age, BMI, and preoperative ASA score) of the two groups were compared, no differences were found (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Tumor location and the presence of distant metastases were determined using computed tomography (CT) and endoscopy prior to surgery. All operations were performed by the same surgical and nursing teams. Samples were processed based on the 15th edition of the Japanese Classification of Gastric Carcinoma (JCGC)[\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e], and tumor, node, and metastasis (TNM) as well as pathological stages were confirmed according to the 8th edition of the American Joint Committee of Cancer (AJCC) guidelines[\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eII. Operative method\u003c/h2\u003e\n\u003cp\u003eThe scope of surgical resection and lymph node dissection was in accordance with the Japanese Gastric Cancer Treatment Guidelines. RAPPG was performed with the patient in the supine position at 15\u003csup\u003eo\u003c/sup\u003e, with the head high and feet low and an assistant on the right side of the patient. After the procedure, the trocar setting was optimized to adopt the \"U\"-shaped layout to avoid a collision with the robotic arm (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThere are two common key technical links between RAPPG and traditional PPG: (1) no. 6 lymph node dissection with preservation of the subpyloric vessels and (2) management of the upper edge of the pancreas with preservation of the coeliac branch of the vagus nerve. However, since the \"immersive\" 3D stereo imaging system of the da Vinci Surgical System can provide a field of view similar to that of open surgery, the movements between the surgeon's control platform and the robotic arm are highly synchronized, and the surgeon can control both the lens and machine simultaneously. This reduces the coordination error with other operators and avoids the \"straight-line effect\" of laparoscopic surgery. This distinction differentiates RAPPG from LAPPG.\u003c/p\u003e\n\u003cp\u003e(1) \u003cstrong\u003eNo. 6 lymph node dissection with preservation of subpyloric vessels\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreserving the vessels around the pylorus can maintain the basic shape of the pylorus and has little effect on the function of the pylorus after PPG. Our team preserved both the inferior pyloric vein and inferior pyloric plexus. Prevention of postoperative pyloric spasm and edema can effectively preserve the gastric emptying function; therefore, it is best to maintain the length of the pyloric canal at 3\u0026ndash;4 cm. In principle, the hepatic and pyloric branches of the anterior vagus were preserved. Moreover, the celiac branch of the vagus was preserved as much as possible. The bifurcation of the right gastroepiploic vessel and the inferior pyloric vessel was considered the center, dissociating and exposing from the upper, lower, right, and left directions, as well as from the ventral and dorsal sides to complete the dissection of the subpyloric lymph nodes.\u003c/p\u003e\n\u003cp\u003eFirst, the lymph nodes in the subpyloric region were dissected along the front of the pancreatic head from the right side. Then, the omentum was opened in the avascular region between the subpyloric vessel and the first branch of the right gastroepiploic vessel, which communicated with the left free plane, and they were each cut off from the gastric wall along the right gastroepiploic vessel branches. The greater curvature of the gastric antrum was exposed 4\u0026ndash;5 cm for amputation and anastomosis. The lymph nodes were dissected downward from the pylorus and duodenum to the bifurcation of the inferior pyloric vessel and the right gastroepiploic vessel. Second, the lymph nodes were dissected from the bottom along the root of the right gastroepiploic vein to the top of the bifurcation. Finally, from the left side of the pancreas, the lymph nodes were dissected along the vessels to the bifurcation, and 4\u0026ndash;5 cm of the right gastroepiploic vessels were circumscribed from the bifurcation as the starting point to complete the subpyloric lymph node dissection. The inferior pyloric artery and vein were preserved together, and the distal end of the right gastroepiploic vessel was clipped and severed by hemo-lock near the bifurcation (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\n\u003cp\u003e\u003cstrong\u003e(2) Protection of the vagus\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe vagus was exposed from the right side of the gastric pancreas. When dissecting the exposed nerve, the output power of the device could be appropriately reduced to avoid burns to the nerve tissue using the energy platform. During the operation, a combination of the right diaphragmatic crus approach, left retroperitoneal approach, and esophageal approach was used to anatomically observe the distribution of the posterior vagus nerve and its branches and to determine the anatomical type of the left gastric vessel. Using the nerve fibers surrounding the artery as a landmark, lymph node dissection outside the nerve fiber membrane was the technical core of this link.\u003c/p\u003e\n\u003cp\u003eArm 4 used grasping forceps to lift the descending branch arch of the left gastric vessel and omental fat tissue together and pull them to the abdominal wall. It can also pull to the left and right sides of the surgical field to facilitate exposure and operation of the surgical field. Here, the assistant carried a piece of gauze to hide the tip of the clamp, pressed the lower one-third of the body of the pancreas, pulled the pancreas to the side of the foot, turned the upper edge of the pancreas outward, and pulled the pancreas to the left and right sides with surgical field transformation. Assistant forceps are usually located outside the surgical field and handled carefully to avoid damage to the pancreas, mesenteric vessels, superior mesenteric vessels, and bowel. Arm 3 used bipolar electrocoagulation or electric scissors to facilitate lymph node dissection and nerve exposure at the upper edge of the pancreas. Arm 1 used grasping forceps to assist with retraction and exposure (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e(3) \u003cstrong\u003eTreatment of the gastric left vessel and cardia esophageal branch\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRetention of the cardia esophageal branch plays an important role in maintaining the morphology and function of the cardia. To maintain its structural integrity, the esophageal hiatus should not be destroyed or opened too much during the procedure (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). The right-sided approach was used to expose the anterior wall of the lesser curvature below the cardia and to determine the esophagocardial branch of the left gastric vessel. Maintaining the shape of the stomach after anastomosis depends on the survival of this branch. At the distal end of the branch, lymph nodes 1 and 3 were cleared along the lesser curvature of the gastric wall and right branch of the diaphragmatic crus. The distal part of the stomach was dissociated from the lower part of the cardia, exposing the bifurcation of the esophagus-cardia branch of the left gastric vessel and the whole proximal to the descending branch of the left gastric vessel (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eA 10-cm midline incision was made in the upper abdomen to lift the stomach, and titanium clips marked under the preoperative endoscope were searched to determine the location of the tumor. To ensure sufficient incision margins, we used in vitro manual gastro-stomach anastomosis (the suture method adopts continuous full-thickness or discontinuous full-thickness sutures) and interrupted the seromuscular embedding suture.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eIII. Index analysis and follow-up study\u003c/h2\u003e\n\u003cp\u003eThe clinicopathological data, surgical status, postoperative complications, postoperative recovery schedule time, feeding time, and postoperative hospital stay of both groups were recorded. Telephone and outpatient follow-up were used to record patient survival status and tumor recurrence. Following surgery, patients were monitored every three months for two years and every six months for the next three to four years after the surgery. This study was conducted until January 2022.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eIV. Statistical methods\u003c/h2\u003e\n\u003cp\u003eData were analyzed using SPSS 21.0, and descriptive statistics were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or as percentages. Data from the measurement and count were compared using the independent sample t-test and the Chi-square test, respectively. Postoperative survival was calculated using the Kaplan-Meier method, and survival was compared using the log-rank test. Statistical significance was set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBoth the RAPPG and LAPPG groups underwent successful operations, and neither group was converted to open surgery. Tumor size (2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 vs. 2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 cm, P\u0026thinsp;=\u0026thinsp;0.257), depth of invasion, histological type, and stage distribution were similar between the two groups, and the mean distal and proximal resection margins were \u0026gt;\u0026thinsp;2 cm in both groups (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The length of the preserved pyloric canal was \u0026gt;\u0026thinsp;2 cm (3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 vs. 3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 cm, P\u0026thinsp;=\u0026thinsp;0.873). The average number of detected lymph nodes in the RAPPG group was slightly higher than that in the LAPPG group (26.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8 vs. 17.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6, P\u0026thinsp;=\u0026thinsp;0.068), but the difference was not statistically significant. There was no difference in the mean number of positive lymph nodes (0.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 vs. 0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7, P\u0026thinsp;=\u0026thinsp;0.734) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe RAPPG group took longer to operate than the LAPPG group (309.3\u0026thinsp;\u0026plusmn;\u0026thinsp;59.9 vs. 236.2\u0026thinsp;\u0026plusmn;\u0026thinsp;36.5 min, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), but the blood loss was significantly less than that in the LAPPG group (39.3\u0026thinsp;\u0026plusmn;\u0026thinsp;31.2 vs. 48.5\u0026thinsp;\u0026plusmn;\u0026thinsp;33.6 mL, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). The postoperative exhaust time, liquid food intake, and drainage tube removal time in the RAPPG group were slightly shorter than those in the LAPPG group, and the differences were statistically significant. The time to discharge was approximately the same in each group, and both groups experienced the same frequency of perioperative complications.\u003c/p\u003e\n\u003cp\u003eBased on the monitoring of the laboratory test indicators of patients during the perioperative period, four patients from the RAPPG group and nine patients from the LAPPG group developed hyperamylase after surgery; all of these patients were successfully treated with intravenous somatostatin. No serious complications occurred, and amylase levels in blood were the same in both groups on the first and third postoperative days (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003ea). Compared with the RAPPG group, the LAPPG group had a higher leukocyte count on the first postoperative day. After postoperative prophylactic antibiotic treatment, there was no significant difference in the WBC count between the two groups on the third postoperative day (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003eb). On the first day after surgery, hemoglobin levels in the LAPPG group were somewhat higher than those in the RAPPG group. On the third postoperative day, the overall hemoglobin levels of the two groups decreased slightly with no statistical difference between the groups (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003ec).\u003c/p\u003e\n\u003cp\u003eDuring the follow-up period, gastric emptying was delayed in one (7.1%) RAPPG patient and four (19.0%) LAPPG patients; moreover, the symptoms of these patients improved with conservative treatment. RAPPG and LAPPG participants were followed up on average for 9.3 months and 16.4 months, respectively. No recurrence occurred during the follow-up periods. None of the patients received adjuvant chemotherapy after surgery, and none of the patients in either group died (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Outpatient follow-up was performed every three months for two years after the operation. The anastomotic stoma healed well in most patients with gastroscopy three months after the operation, and anastomotic stomatitis was occasionally observed (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003ea). The patients were given dietary guidance and acid suppression was added if necessary; anastomotic stomatitis was mostly relieved at six to nine months after the operation (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003eb). Upper gastrointestinal angiography revealed good pyloric systolic function and gastric emptying (Figs.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003ec-\u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003ed).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMinimally invasive surgery for GC has been widely used clinically to improve outcomes in patients undergoing gastrectomy. Postoperative benefits include reduced pain, lower risk of complications, decreased blood loss, shorter hospital stays, and earlier return to normal activities. Since its introduction in the late 1990s, the robotic surgical system has provided a breakthrough in the minimally invasive treatment of GC. The robotic surgical system is more suitable for abdominal surgery in some special areas, such as proximal gastrectomy, procedures related to the hepatic curvature of the colon, splenic resection, and low rectal resection. Robotic surgical systems are excellent for long-term, delicate, and complicated abdominal operations, such as function-preserving surgery (PPG, distal gastrectomy with vagus nerve preservation, and lateral lymph node clearance), pancreaticoduodenectomy, complex liver and biliary surgery, and vascular anastomosis; their main advantages are that they filter tremors, they have multi-dimensional motor mechanical arms, they allow deep regional lymph node dissection, and they provide tissue and organ protection during lymph node dissection[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe detection rate of EGC has gradually improved with the popularization of GC screening and endoscopic diagnosis. Function-preserving surgery has become a major strategy for improving the quality of life of patients after gastrectomy for EGC. In recent years, PPG, known as the Maki surgery, has been widely used for the treatment of EGC (cT1N0M0) located in the middle part of stomach and the distal edge from the pylorus (\u0026gt;\u0026thinsp;4 cm). This specific placement ensures that the distal end of the tumor is 2 cm away from the lower resection margin and the lower resection margin is \u0026ge;\u0026thinsp;2 cm away from the pyloric canal to reduce the scope of gastrectomy. Preserving the pylorus and vagus nerves can significantly improve the quality of life of patients after surgery and reduce the incidence of postoperative dumping syndrome, bile reflux, and cholelithiasis; moreover, the oncological results are satisfactory[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. RAPPG combines a minimally invasive concept and functional retention with the advantages of minimal invasiveness and early postoperative rehabilitation; however, there are few reports on RAPPG surgery.\u003c/p\u003e \u003cp\u003eHashizume first reported that the da Vinci Surgical System was used for the treatment of GC and achieved good results[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Several studies have shown the safety and feasibility of da Vinci robotic surgery for the treatment of GC. Our department has summarized its previous experience with da Vinci robotic surgery and believes that da Vinci RAPPG is safe and feasible[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The primary purpose of PPG surgery is to preserve the gastric function, namely the emptying and anti-reflux functions. More effective and accurate preservation of the vagal nerve branch, subpyloral vessels, and left gastric vessels is the key focus of surgical success, and the da Vinci Surgical System undoubtedly provides more favorable conditions for surgeons.\u003c/p\u003e \u003cp\u003eRecent studies on robotic gastrectomy for GC suggest that robotic surgical outcomes are superior to the outcomes of laparoscopic surgery, especially in terms of perioperative blood loss, surgery-related morbidity of postoperative complications, and length of hospital stay[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our team\u0026rsquo;s study also suggests that the bleeding amount of the da Vinci surgery group was less than that of the laparoscopic group. While there were benefits from the improved field of vision and stable operation, there were also benefits from the energy platform, as the team routinely used the Arm 1 bipolar electrocoagulation and Arm 3 electrical scissors, which quickly and effectively achieved hemostasis. The postoperative exhaust and diet recovery time in the RAPPG group was better than that in the LAPPG group, and the average postoperative hospital stay was 1.1 days shorter in the RAPPG group than that in the LAPPG group.\u003c/p\u003e \u003cp\u003eHowever, the time and cost of robotic surgery are consistent with its application; both were higher than those in the LAPPG group[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A long operation time is one of the factors that limits the development of robotic surgery and may be overcome with extensive operative experience. In addition, robotic surgery is not included in medical insurance in China, and its cost is approximately 15,000\u0026ndash;30,000 RMB higher than that of laparoscopic surgery, which is also one of the lagging factors for its widespread development. Finally, related studies revealed that the detection rate of lymph nodes in the robotic surgery system was higher, and more lymph nodes were detected in the upper pancreatic area (groups 7-12a) (14.5 vs 11.3, P\u0026thinsp;=\u0026thinsp;0.023) in our study[\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, more clinical data are needed for validation. Even though the average number of lymph nodes detected in the RAPPG group was slightly higher than that in the LAPPG group, the difference was not statistically significant.\u003c/p\u003e \u003cp\u003eIn addition, we routinely marked a metal titanium clip at the proximal end of the tumor through endoscopy before surgery and combined this technique with upper gastrointestinal angiography to determine the location of the tumor and formulate the scope of surgical resection. We sometimes combined it with magnifying endoscopy to determine the size and boundary of the tumor. By touching these metal clips during surgery, the extent of the gastrectomy could be determined. Intraoperative frozen pathology to confirm negative proximal and distal margins was required.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe overall effect of RAPPG surgery was satisfactory. It effectively overcame the \"chopstick effect\u0026rdquo; and \"straight-line effect\u0026rdquo; of laparoscopic surgery and had a field of view and free adjustment similar to those of open surgery. The learning curve was shorter for surgeons with experience in open surgery. Our department could independently perform intraoperative gastroscopy. Using robotic technology, surgeons can achieve real-time dynamic navigation, accurately locate the lesion, and complete more precise operations to ensure accurate and complete resection of EGC. In summary, robotic radical gastrectomy still has many advantages over ordinary laparoscopic surgery, including the learning curve, controlling blood loss, surgical precision, and quick recovery. The treatment of EGC can achieve a satisfactory prognosis and can effectively control surgical risk and postoperative complications. Moreover, while achieving the purpose of radical resection, the concept of minimally invasive surgery may be better utilized, and the quality of life of patients after surgery can be improved. With a future series of prospective multicenter clinical studies, various robotic surgical methods may be standardized, and we believe that this application of minimally invasive technology in the treatment of GC will broaden.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eGC: gastric cancer; EGC: early gastric cancer; PPG: pylorus-preserving gastrectomy; LAPPG: pylorus and vagus-preserving gastrectomy; RAPPG: robot-assisted pylorus and vagus-preserving gastrectomy\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eX.H. designed the study; C.F.and H.W. were co-first authors and contributed maximally and equally to the study; C.F. and H.W. collected and analyzed the data; C.Z. and X.H interpreted the data; C.F. drafted the manuscript; P.L. and X.H. revised the manuscript. The authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll experimental data used to support these findings are included in the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the First Affiliated Hospital of Dalian Medical University. Written informed consent for publication was obtained from all patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patients and legal guardian for the publication of these patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWang FH, Zhang XT, Li YF, Tang L, Qu XJ, Ying JE, Zhang J, Sun LY, Lin RB, Qiu H, et al: \u003cb\u003eThe Chinese Society of Clinical Oncology (CSCO): Clinical guidelines for the diagnosis and treatment of gastric cancer, 2021\u003c/b\u003e. 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J Gastric Cancer 2016, \u003cb\u003e16\u003c/b\u003e:63\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAJGC: \u003cb\u003eJapanese Gastric Cancer Treatment Guidelines\u003c/b\u003e. \u003cb\u003e6th\u003c/b\u003e. \u003cem\u003eBerlin, Germany: Springer\u003c/em\u003e 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNomura E, Okajima K: \u003cb\u003eFunction-preserving gastrectomy for gastric cancer in Japan\u003c/b\u003e. World J Gastroenterol 2016, \u003cb\u003e22\u003c/b\u003e:5888\u0026ndash;5895.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan DS, Suh YS, Ahn HS, Kong SH, Lee HJ, Kim WH, Yang HK: \u003cb\u003eComparison of Surgical Outcomes of Robot-Assisted and Laparoscopy-Assisted Pylorus-Preserving Gastrectomy for Gastric Cancer: A Propensity Score Matching Analysis\u003c/b\u003e. 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Ann Surg Oncol 2017, \u003cb\u003e24\u003c/b\u003e:3683\u0026ndash;3691.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoratti A, Annecchiarico M, Di Marino M, Gentile E, Coratti F, Giulianotti PC: \u003cb\u003eRobot-assisted gastrectomy for gastric cancer: current status and technical considerations\u003c/b\u003e. World J Surg 2013, \u003cb\u003e37\u003c/b\u003e:2771\u0026ndash;2781.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNunobe S, Sasako M, Saka M, Fukagawa T, Katai H, Sano T: \u003cb\u003eSymptom evaluation of long-term postoperative outcomes after pylorus-preserving gastrectomy for early gastric cancer\u003c/b\u003e. Gastric Cancer 2007, \u003cb\u003e10\u003c/b\u003e:167\u0026ndash;172.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHashizume M, Shimada M, Tomikawa M, Ikeda Y, Takahashi I, Abe R, Koga F, Gotoh N, Konishi K, Maehara S, Sugimachi K: \u003cb\u003eEarly experiences of endoscopic procedures in general surgery assisted by a computer-enhanced surgical system\u003c/b\u003e. Surg Endosc 2002, \u003cb\u003e16\u003c/b\u003e:1187\u0026ndash;1191.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTian Y, Cao S, Kong Y, Shen S, Niu Z, Zhang J, Chen D, Jiang H, Lv L, Liu X, et al: \u003cb\u003eShort- and long-term comparison of robotic and laparoscopic gastrectomy for gastric cancer by the same surgical team: a propensity score matching analysis\u003c/b\u003e. Surg Endosc 2022, \u003cb\u003e36\u003c/b\u003e:185\u0026ndash;195.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKinoshita T, Sato R, Akimoto E, Tanaka Y, Okayama T, Habu T: \u003cb\u003eReduction in postoperative complications by robotic surgery: a case-control study of robotic versus conventional laparoscopic surgery for gastric cancer\u003c/b\u003e. Surg Endosc 2022, \u003cb\u003e36\u003c/b\u003e:1989\u0026ndash;1998.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlhossaini RM, Altamran AA, Cho M, Roh CK, Seo WJ, Choi S, Son T, Kim HI, Hyung WJ: \u003cb\u003eLower rate of conversion using robotic-assisted surgery compared to laparoscopy in completion total gastrectomy for remnant gastric cancer\u003c/b\u003e. Surg Endosc 2020, \u003cb\u003e34\u003c/b\u003e:847\u0026ndash;852.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarano L, Fusario D, Savelli V, Verre L, Neri A, Marrelli D, Roviello F: \u003cb\u003eRobotic versus laparoscopic gastrectomy for gastric cancer: protocol for umbrella review of systematic reviews and meta-analyses\u003c/b\u003e. BMJ Open 2020, \u003cb\u003e10\u003c/b\u003e:e033634.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsobe T, Murakami N, Minami T, Tanaka Y, Kaku H, Umetani Y, Kizaki J, Aoyagi K, Fujita F, Akagi Y: \u003cb\u003eRobotic versus laparoscopic distal gastrectomy in patients with gastric cancer: a propensity score-matched analysis\u003c/b\u003e. BMC Surg 2021, \u003cb\u003e21\u003c/b\u003e:203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen K, Pan Y, Zhang B, Maher H, Wang XF, Cai XJ: \u003cb\u003eRobotic versus laparoscopic Gastrectomy for gastric cancer: a systematic review and updated meta-analysis\u003c/b\u003e. BMC Surg 2017, \u003cb\u003e17\u003c/b\u003e:93.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e "}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"robotic surgery, gastric cancer, vagus nerve, pylorus, gastrectomy","lastPublishedDoi":"10.21203/rs.3.rs-1961065/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1961065/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study aimed to assess the efficacy, feasibility, and safety of robot-assisted pylorus- and vagus nerve-preserving gastroplasty (RA[PPG]), using the da Vinci Surgical System, compared with those of laparoscopy-assisted PPG (LAPPG).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eClinical and follow-up data of patients who underwent PPG were retrospectively analyzed, which included 14 RAPPG and 21 LAPPG cases. The histological data, surgical results, postoperative recovery, and complication rates were compared between the two groups; the surgical experience was also summarized.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe operation time was slightly longer in the RAPPG group (309.3\u0026thinsp;\u0026plusmn;\u0026thinsp;59.9 vs. 236.2\u0026thinsp;\u0026plusmn;\u0026thinsp;36.5 min, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), but this group had less intraoperative bleeding. The length of the preserved pyloric canal, number of dissected lymph nodes, postoperative recovery, and overall complication rates were not significantly different. The proportion of delayed gastric emptying and acid reflux symptoms in the LAPPG group was slightly greater than that in the RAPPG group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe da Vinci Surgical System is a safe and feasible way to control the postoperative gastric emptying speed and to effectively reduce reflux.\u003c/p\u003e","manuscriptTitle":"Da Vinci robot-assisted pylorus- and vagus nerve-preserving gastrectomy for early gastric cancer: A single-center study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-08-19 17:39:42","doi":"10.21203/rs.3.rs-1961065/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fe19ed15-c82a-4f81-98a2-8b8d6134bd61","owner":[],"postedDate":"August 19th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-09-16T16:14:29+00:00","versionOfRecord":[],"versionCreatedAt":"2022-08-19 17:39:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1961065","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1961065","identity":"rs-1961065","version":["v1"]},"buildId":"369fNeqWncA4NS6XSWjrt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}