Severe postoperative complications after minimally invasive esophagectomy reduce the long-term prognosis of well-immunonutrition patients with locally advanced esophageal squamous cell carcinoma

BACKGROUND

While severe postoperative complications (SPCs) impact cancer prognosis, their effect on locally advanced esophageal squamous cell carcinoma (ESCC) patients with varying immunonutritional statuses after minimally invasive esophagectomy (MIE) is unclear.

METHODS

This retrospective study analyzed 442 patients with locally advanced ESCC who underwent MIE, investigating the relationship between SPCs and survival based on preoperative immunonutritional status, determined by the prognostic nutritional index (PNI). Nomograms were developed for patients with preserved immunonutritional status using Cox regression, and their performance was assessed.

RESULTS

Of the patients, 102 (23.1%) experienced SPCs after MIE. Five-year overall survival (OS) and disease-free survival (DFS) were significantly different between SPCs and non-SPCs groups (p < 0.001). In the preserved immunonutritional group, SPCs significantly reduced 5-year OS (p = 0.008) and DFS (p = 0.011), but not in the poor immunonutritional group (OS p = 0.152, DFS p = 0.098). Multivariate Cox regression identified SPCs as an independent risk factor for OS (HR = 1.653, p = 0.013) and DFS (HR = 1.476, p = 0.039). A nomogram for predicting OS and DFS in preserved immunonutritional patients demonstrated excellent performance.

CONCLUSIONS

SPCs significantly affect prognosis in ESCC patients with preserved immunonutritional status after MIE. Nomograms based on SPCs can predict OS and DFS in these patients.

Detection of pathologic complete response using deep neural network-based endoscopic evaluation in patients with esophageal cancer receiving neoadjuvant chemotherapy: a nationwide multicenter retrospective study from 46 Japanese esophageal centers

BACKGROUND

Detecting pathological complete response (pCR) preoperatively facilitated a non-surgical approach after neoadjuvant chemotherapy (NAC). We previously developed a deep neural network-based endoscopic evaluation to determine pCR preoperatively. Its quality warrants improvement with a larger data series for clinical application.

METHODS

This study retrospectively reviewed patients with esophageal squamous cell carcinoma (ESCC) receiving NAC at 46 Japanese esophageal centers certified by the Japan Esophageal Society. Endoscopic images after NAC were collected with clinicopathological factors and long-term outcomes. We randomly selected the same number of patients with Grades 0-1a and Grades 1b-2 based on those with pCR (Grade 3). A deep neural network was used for endoscopic image analyses. A test data set, consisting of 100 photos, was utilized for validation. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the deep neural network-based model and experienced physicians were calculated.

RESULTS

The study enrolled 1041 patients, including 354 (33%) patients with pCR, the same number of histological non-responders (Grade 0-1a/1b-2, 352 [33%]/368 [34%]). The median values of sensitivity, specificity, PPV, NPV, and accuracy for pCR detection were 80%, 90%, 89%, 82%, and 85%, respectively. The patients with pCR preoperatively demonstrated significantly better overall survival and recurrence-free survival.

CONCLUSIONS

This large-scale study revealed that the deep neural network-based endoscopic evaluation after NAC identified pCR with feasible accuracy. The current artificial intelligence technology may guide an individualized treatment strategy, including a non-surgical approach, in patients with ESCC through prospective studies with careful external validation.

Identification and Categorization of Technical Errors and Hazard Zones of Robotic Versus Laparoscopic Total Gastrectomy for Gastric Cancer: A Single-center Prospective Randomized Controlled Study

OBJECTIVE

The current research aimed to conduct a detailed analysis of intraoperative surgical performance, short-term outcomes, identify and categorize technical errors, and hazard zones enacted during total gastrectomy performed robotically and laparoscopically by surgeons. Prospective research is needed to determine whether the technical advantages of robotic surgery translate to patient outcomes.

BACKGROUND

At present, a growing number of clinical studies have demonstrated that the quality of intraoperative surgical performance has a direct impact on the clinical outcomes of the patient. The current research aimed to conduct a detailed analysis of intraoperative surgical performance and short-term outcomes, and identify and categorize technical errors, and hazard zones enacted during total gastrectomy performed robotically and laparoscopically by surgeons.

METHODS

Eighty-two patients were recruited and participated in this study, with 40 cases undergoing RTG and 42 cases for LTG. Patients undergoing RTG and LTG were recruited and randomized into the study. Six consultant/attending surgeons participated in this study and all surgical procedures were recorded. The unedited surgical video recordings were handed over to third-party experts for granular analysis of the procedures using objective clinical human reliability analysis for the quality of intraoperative performance, technical errors, and intraoperative complications.

RESULTS

The technical errors enacted and identified in the RTG and the LTG were 46.11 ± 5.63 versus 58.79 ± 8.45 ( P < 0.001), respectively. The highest number of technical errors was identified during the dissection of the supra-pancreatic lymph nodes (task zone 3), including No. 5, 7, 8a, 9, 11p, and 12a to complete the nodal clearance around the celiac artery and its trifurcation (7.29 ± 1.88 vs 9.43 ± 2.24, P < 0.001) in both RTG and LTG. The number of lymph nodes harvested with RTG was higher than LTG (35.36 ± 7.51 vs 30.54 ± 6.95, P = 0.016), especially in the upper margin of the pancreas (13.32 ± 4.17 vs 9.36 ± 3.81, P < 0.001). The total cost of hospitalization in the RTG group is 3% more than the LTG group ($15953.41±3533.91 vs $12198.26±2761.27, P < 0.001).

CONCLUSIONS

This study offers compelling objective clinical human reliability analysis evidence demonstrating that RTG facilitates significantly superior technical performance compared with LTG. Whether examining short-term clinical outcomes or intraoperative operations, the robotic surgery system consistently outperforms laparoscopic surgery. Lymph node dissection in the supra-pancreatic region emerged as a major hazard zone in both procedures.

Minimally invasive lymphadenectomy for gastric cancer: Could the robotic approach provide any benefits than laparoscopy?

Gastrectomy is the cornerstone of treatment for gastric cancer. Since the introduction of minimally invasive techniques, the main challenge for surgeons has been to achieve the same surgical radicality, adequate lymphadenectomy, and negative resection margins as with the open approach. Previous Eastern trials showed non-inferiority of laparoscopic gastrectomy, whereas Western trials reported a higher number of complications. This may depend on the different eligibility criteria to select patients and surgeons. Currently, the increased availability of robotic systems has led to renewed enthusiasm. We present a critical review of published randomized control trials (up to October 2024) to investigate the real benefits of robotic compared to open and laparoscopic approaches. Robotic gastrectomy has shown similar oncological outcomes in survival and lymph node retrieval, particularly in suprapancreatic stations, with the advantage of a more acceptable rate of pancreatic fistula and feasible anastomotic reconstruction. Some clinical situations, such as postchemotherapy interstitial fibrosis and distortion of anatomical planes, may increase the technical difficulty. Only four published trials assessed the implications of a pre-operative therapy, with no robotic surgery cases. Robotic systems may reduce intraoperative blood loss, the risk of conversion and allow more extensive lymphadenectomies in cancers with a high risk of extraperigastric metastases, or with clinically proven para-aortic node metastases, although clinical trials evaluating robotic gastrectomy after neoadjuvant therapy have not yet been published.

Asia Pacific Gastroesophageal Cancer Congress (APGCC) 2024 consensus statement on stage 2 and 3 locally advanced gastric and Siewert 3 junctional adenocarcinoma

BACKGROUND

While the development in multimodal therapies has helped improve treatment outcomes for patients with locally advanced gastric adenocarcinoma (LAGC), there still exist disparities in opinion with an optimal treatment plan. This consensus hopes to provide clinicians with structured guidelines to aid in the decision-making for treatment options for LAGC.

METHODS

The consensus statement was initiated by establishing a taskforce in collaboration with the Asia Pacific Gastroesophageal Cancer Congress (APGCC) and a multidisciplinary expert panel was selected. Clinical questions on LAGC where perceived variance in practice or opinion may exist were formulated. Studies involving patients with Stage 2 or 3 gastric or Siewert 3 junctional cancers with treatment arms of perioperative chemotherapy, neoadjuvant chemotherapy, adjuvant chemotherapy, immunotherapy and surgery were included. A total of two rounds of voting were performed. Consensus was determined to be reached when a single answer or a combination of either "strongly agree/agree" or "strongly disagree/disagree" responses exceeded 75%.

RESULTS

A total of thirteen clinical questions were developed. They were identified through five main categories: Distal LAGC, Proximal LAGC, Deficient mismatch repair tumors, Chemotherapy and Immunotherapy, and Elderly/Unfit patients. After two rounds of voting by our multidisciplinary expert panel, eleven out of a total thirteen clinical questions had reached consensus. No consensus was reached for two clinical questions.

CONCLUSION

The APGCC consensus statement aims to guide clinicians in the treatment options for LAGC and Siewert 3 junctional cancer and has clarified some of the roles of perioperative chemotherapy and immunotherapy.

Development in Esophagectomy for Esophageal Cancer: The Current Standing Point of Robotic Surgery

Despite advancements in multidisciplinary treatment, esophagectomy remains the primary curative treatment for esophageal cancer. Given that lymph node metastases can spread from the cervical to abdominal regions, three-field lymph node dissection has been established as a standard approach. However, this highly invasive procedure involves multiple anatomical regions-thoracic, abdominal, and cervical-leading to significant surgical burden. To reduce surgical invasiveness, minimally invasive esophagectomy (MIE) has become increasingly common worldwide. With its adoption and advancements in multidisciplinary therapy, discussions have emerged regarding the potential omission of lymph node dissection in selected cases. Since the introduction of robot-assisted minimally invasive esophagectomy (RAMIE) in 2004, this technique has progressively replaced conventional MIE. Robotic systems-equipped with a magnified 3D camera, articulated instruments, and tremor filtering-allow surgeons to perform complex procedures with greater precision than manual techniques. One randomized controlled trial (RCT) has demonstrated fewer postoperative complications with RAMIE compared to open esophagectomy. Additionally, RAMIE has been shown to enable more extensive lymph node dissection around the left recurrent laryngeal nerve than conventional MIE. However, the long-term oncological benefits of RAMIE remain unproven, as no RCTs have definitely confirmed its impact on long-term survival in esophageal cancer patients. Ongoing randomized trials are expected to provide further insights into its prognostic benefits.

Efficacy and safety of polyglycolic acid sheets for prevention of intra-abdominal infectious complications following minimally invasive surgery for gastric cancer: A prospective, multicenter, single-arm clinical trial

BACKGROUND

Serious intra-abdominal infectious complications are common after gastric cancer surgery, including anastomotic leakage, pancreatic fistula, and intra-abdominal abscess. Although polyglycolic acid sheets are often used to reinforce soft tissue and prevent postoperative complications in various types of surgery, including gastric cancer surgery, their effectiveness has not yet been fully demonstrated.

METHODS

Patients with gastric cancer and no distant metastasis undergoing minimally invasive distal or total gastrectomy at Kyoto University Hospital or its 9 affiliated facilities between March 2022 and December 2023 were enrolled. The primary outcome was incidence of Clavien-Dindo (CD) grade ≥ III intra-abdominal infectious complications, including anastomotic leakage, pancreatic fistula, and intra-abdominal abscess. Secondary outcomes were incidence of overall complications (CD grade ≥ III), pancreatic fistula (CD grade ≥ III), or anastomotic leakage (CD grade ≥ III).

RESULTS

In total, 210 patients were included. Distal gastrectomy was performed in 186 cases (88.6 %) and total gastrectomy in 24 (11.4 %). No cases required conversion to laparotomy. The incidence of CD grade III intra-abdominal infectious complications was 1.4 % (90 % confidence interval 0.6-3.5), below the pre-defined limit of 7.0 %. The rate of CD grade ≥ III overall complications was 4.3 %, that of CD grade ≥ III pancreatic fistula was 1.0 %, and that of CD grade ≥ III anastomotic leakage was 0.5 %. The polyglycolic acid sheet was not associated with any serious complications or abnormal laboratory values.

CONCLUSION

Polyglycolic acid sheets were safe and effective in preventing serious intra-abdominal infectious complications after minimally invasive surgery for gastric cancer. TRIAL REGISTRY NUMBER: jRCTs052210188.

Impact of spinal anesthesia on myocardial damage, ultrastructure and cellular mechanisms in rats undergoing thoracic incision surgery

AIMS

This study aimed to investigate the impact of surgery on cardiac injury and microscopic ultrastructural changes in the heart, as well as the potential protective cellular mechanisms of spinal anesthesia.

METHODS

Male Sprague-Dawley rats were randomly assigned to four groups: Control (regular rats), Sham (received spinal saline injection), Surgery (received spinal saline followed by surgery) and Bupivacaine (received spinal bupivacaine 0.5 %, 50 μL followed by surgery), and Bupivacaine (received spinal bupivacaine 0.5 %, 50 μL followed by surgery). The serum and hearts of the rats were assessed for troponin I, NT-proBNP, electron microscopy, catecholamines, markers of oxidative stress and endoplasmic reticulum stress, as well as apoptosis and autophagy.

RESULTS

After surgery, the hearts showed signs of injury, with decreased tissue troponin I and elevated NT-proBNP levels. Electron microscopy revealed mitochondrial swelling, disarrangement and cytosolic vacuoles. Serum epinephrine levels and expression of β1 and β2 adrenergic receptors were elevated. Serum nitrate and nitrite levels (markers of oxidative stress), along with the ER stress indicator GRP78 and autophagy indicators LC3 and LAMP-1, were heightened, and cardiomyocyte apoptosis increased. These effects can be mitigated with the use of spinal bupivacaine.

CONCLUSIONS

Surgery can cause ultrastructural and cellular damage, elevate sympathetic activity, oxidative stress, and endoplasmic reticulum stress, leading to autophagy and cardiomyocyte apoptosis. Spinal anesthesia can protect the heart from these injuries.

Retroperitoneal-First Laparoscopic Approach (Retlap)-Assisted Additional Lymph Node Dissection for Incidental Gallbladder Cancer: A Novel and Reasonable Approach to the Hepatoduodenal Ligament

BACKGROUND

The incidence of incidental gallbladder cancer (IGBC) has been reported to be approximately 1% in patients undergoing cholecystectomy.1 The guidelines recommend additional lymph node dissection for IGBC invading the subserosal layer or deeper;2 however, two-stage surgery is expected to involve abdominal adhesions, and lymph node dissection of the pancreatic head dorsal area is technically complicated because of poor views and the necessity of colon mobilization in cases using the conventional intra-abdominal approach. The retroperitoneal-first laparoscopic approach (Retlap) was reported by Kiguchi et al. as a minimally invasive surgical procedure for advanced pancreatic body cancer, which is not affected by the intraperitoneal situation.3,4 Applying this technique, we performed Retlap-assisted additional lymph node dissection for IGBC.

METHODS

A 59-year-old woman underwent laparoscopic cholecystectomy for symptomatic cholelithiasis, and IGBC was diagnosed based on a pathological examination. The depth of invasion was T3a, and additional lymph node dissection was performed using Retlap.

RESULTS

The operation time was 326 min, the retention time was 153 min, and the estimated blood loss was 30 mL. The patient was discharged on the sixth postoperative day without any complications. Pathologically, 13 lymph nodes were dissected but there were no malignant findings.

CONCLUSION

Retlap-assisted additional lymph node dissection for IGBC is not affected by intra-abdominal adhesions, provides a good visual field, does not require mobilization of the colon, and allows minimally invasive surgery. Since the robotic approach for IGBC has already been safely implemented,5 we aim to apply the robotic approach when using Retlap in the future.

Comparison of short-term outcomes for robotic rectal surgery between the hinotori™ surgical robot system and da Vinci surgical system: a single-center retrospective study using propensity score matching analysis

BACKGROUND

Robotic surgery for rectal cancer has grown popular in recent years and has primarily used the da Vinci Surgical System (Intuitive Surgical, CA, USA; da Vinci). In 2020, Japan introduced the hinotori™ Surgical Robot System (Medicaroid, Kobe, Japan; hinotori). We report our initial surgical experiences with robotic surgery using hinotori for rectal cancer and its feasibility and safety comparing with da Vinci.

METHODS

A single-institution retrospective study was conducted. Between November 2022 and November 2023, 38 and 96 patients with rectal cancer underwent robotic surgery using hinotori and da Vinci, respectively. The primary endpoint was the incidence of postoperative complications of the Clavien-Dindo classification (CD) grade ≥ II within postoperative 30 days. Secondary endpoints included surgical and console time, blood loss, conversion to other approaches, number of dissected lymph nodes, and postoperative hospital stay. A propensity score matching (PSM) analysis was used to adjust for imbalance in baseline characteristics.

RESULTS

After PSM, a total of 76 patients (hinotori: 38, da Vinci: 38) were included. Compared to the da Vinci group, the hinotori group showed a similar postoperative complication rate of CD ≥ II (15.8% vs. 18.4%), comparable operative time (280.5 vs. 258 min), comparable console time (166 vs. 156 min), and less blood loss (9 vs. 17.5 mL, p = 0.025). There was no conversion in either group. The number of dissected nodes and postoperative stay were similar between the two groups.

CONCLUSION

Our findings support that robotic surgery for rectal cancer using hinotori is as safe as surgery performed using the da Vinci system.

Protein Ubiquitination Modification in Pulmonary Fibrosis

Pulmonary fibrosis (PF) is a chronic, progressive fibrotic interstitial lung disease characterized by a high incidence and mortality rate, which encompasses features, such as diffuse alveolar inflammation, invasive fibroblast activation, and uncontrolled extracellular matrix (ECM) deposition. Beyond the local pathological processes, PF can be better understood in light of interorgan communication networks that are involved in its progression. Notably, pulmonary inflammation can affect cardiovascular, renal, hepatic, and neural functions, highlighting the importance of understanding these systemic interactions. Posttranslational modifications play a crucial role in regulating protein function, localization, stability, and activity. Specifically, protein ubiquitination modifications are involved in PF induced by various stimuli, involving a range of ubiquitin-modifying enzymes and substrates. In this review, we provide an overview of how E3 ubiquitin ligases and deubiquitinating enzymes (DUBs) modulate PF through several signaling pathways, such as TGF-β, Wnt, metabolic activity, aging, ferroptosis, endoplasmic reticulum stress, and inflammatory responses. This perspective includes the role of ubiquitin-proteasome systems in interorgan communication, affecting the progression of PF and related systemic conditions. Additionally, we also summarize the currently available therapeutic compounds targeting protein ubiquitination-related enzymes or ubiquitination substrates for the treatment of PF. Understanding the interplay between ubiquitination and interorgan communication may pave the way for novel therapeutic strategies.

Feasibility of the hinotori™ surgical robot system in right colectomy: a propensity score matching study

BACKGROUND

Robotic surgery, represented by the da Vinci™ system (hereafter da Vinci), has been adopted worldwide owing to its high precision and improved surgical outcomes. After key patents for da Vinci expired, the hinotori™ system (hereafter hinotori), Japan's first domestically developed surgical robot system, was introduced and received clinical approval in November 2022. Although hinotori is introduced as an alternative to da Vinci, its clinical performance in gastrointestinal surgery, particularly in colectomy, remains unclear. This study provided an overview of the surgical techniques for right colectomy using hinotori and retrospectively compared its short-term clinical outcomes with those of da Vinci, post-adjusting for background factors using propensity score matching (PSM).

METHODS

Data from 88 consecutive patients who underwent robotic right colectomy at our institute between 2020 and 2024 were retrospectively reviewed. Patients were classified into the hinotori (n = 28) and da Vinci (n = 60) groups. PSM resulted in 26 patients being assigned to each group. Patient demographics, perioperative outcomes, pathological findings, and complication rates were analyzed and compared between the groups. Patients in both groups underwent standardized surgical procedures performed by the same surgeons using intracorporeal anastomosis. Role switching between the assistant and primary surgeon was required for some procedural steps owing to instrumentation limitations of hinotori.

RESULTS

No significant differences were observed in patient demographics between the propensity score-matched groups. Operative (277.5 vs. 242.5 min, p = 0.044) and console (210 vs. 184.5 min, p = 0.047) times were significantly longer in the hinotori group than in the da Vinci group. No significant differences in blood loss, Clavien-Dindo grade III or higher complications, or postoperative hospital stay were found between the groups. Both groups had comparable histopathological outcomes, including lymph node yield and resection margins.

CONCLUSION

Our findings suggest that perioperative outcomes in robotic right colectomy using hinotori are comparable to those of da Vinci.

Laparoscopic gastrectomy reduced peritoneal recurrence in Borrmann type IV gastric cancer: a retrospective cohort study with propensity score matching

BACKGROUND

Current evidence on the surgical and oncological safety of laparoscopic surgery in patients with Borrmann type IV (B-IV) advanced gastric cancer (AGC) remains insufficient. This study aimed to compare the surgical and prognostic outcomes of laparoscopic gastrectomy (LG) and open gastrectomy (OG) in patients with B-IV AGC.

METHODS

Patients with primary B-IV gastric cancer who underwent LG or OG between 2003 and 2019 were retrospectively analyzed. We conducted 1:1 propensity score matching using covariates including sex, age, body mass index, operation type, clinical T and N stages, pathological TNM stage, tumor size, and tumor location. Surgical outcomes, postoperative complications, 5-year survival and recurrence outcomes, and risk factors for peritoneal recurrence were compared between the two groups.

RESULTS

Of 401 patients enrolled, 106 from each of the LG and OG groups were matched, with all standardized differences < 0.1. The LG had significantly fewer wound infections (P = 0.029), intra-abdominal abscesses (P = 0.035) and a lower peritoneal recurrence rate (5-year cumulative incidence: 48.8% vs. 62.8%, P = 0.032; hazard ratio, 0.66; 95% confidence interval, 0.45-0.96) compared to the OG group, along with a trend toward improved 5-year overall survival (LG vs. OG: 37.0% vs. 26.2%, P = 0.174; hazard ratio, 0.78; 95% confidence interval, 0.55-1.11). Multivariate analyses revealed a 32.6% decrease in the hazard ratio for peritoneal recurrence in the LG group (P = 0.048).

CONCLUSIONS

LG significantly reduced peritoneal recurrence with fewer wound and intra-abdominal infectious complications in patients with B-IV AGC.

Postoperative Serum Interleukin 6 Concentrations Are Associated With Nutritional Status and Prognosis of Esophageal Cancer in the Minimally Invasive Esophagectomy Era

BACKGROUND

Findings have shown that preoperative serum interleukin 6 (IL-6) concentrations are associated with treatment response and prognosis of patients with esophageal cancer. However, it has been unclear whether IL-6 concentrations after minimally invasive esophagectomy (MIE) have an impact on nutritional status and prognosis.

METHODS

The cohort of this retrospective study comprised 336 patients who had undergone MIE with R0 for esophageal cancer from August 2020 to August 2022. The study investigated the relationship between postoperative serum IL-6 concentrations and outcomes.

RESULTS

The study created low-IL-6 (<60 pg/mL) and high-IL-6 (≥60 pg/mL) groups according to the upper-quartile postoperative serum IL-6 concentration 1 day after MIE. The high-IL-6 group had a significantly worse overall survival (OS) (2-year OS rate, 69.8% in high-IL-6 vs 80.6% in low-IL-6 group; p = 0.004). A high IL-6 was independently and significantly associated with poor OS (odds ratio, 1.548; 95% confidence interval, 1.027-2.335; p = 0.037). Several indices of malnutrition, including the modified Glasgow prognostic score (mGPS), 1 month after surgery, were significantly lower in the high-IL-6 group than in the low-IL-6 group. Multivariate analysis identified high serum IL-6 concentration 1 day after surgery as an independent risk factor for malnutrition.

CONCLUSION

The ultra-early postoperative serum IL-6 concentration has a negative impact on the nutrition and prognosis of patients who have undergone MIE for esophageal cancer. Decreasing serum IL-6 concentrations after esophagectomy may improve nutritional status and prognosis. It may be important for perioperative management and treatment strategies to target IL-6 after esophageal cancer surgery.

Porphyromonas gingivalis aggravates atherosclerotic plaque instability by promoting lipid-laden macrophage necroptosis

At advanced phases of atherosclerosis, the rupture and thrombogenesis of vulnerable plaques emerge as primary triggers for acute cardiovascular events and fatalities. Pathogenic infection such as periodontitis-associated Porphyromonas gingivalis (Pg) has been suspected of increasing the risks of atherosclerotic cardiovascular disease, but its relationship with atherosclerotic plaque destabilization remains elusive. Here we demonstrated that the level of Pg-positive clusters positively correlated with the ratio of necrotic core area to total atherosclerotic plaque area in human clinical samples, which indicates plaque instability. In rabbits and Apoe-/- mice, Pg promoted atherosclerotic plaque necrosis and aggravated plaque instability by triggering oxidative stress, which led to macrophage necroptosis. This process was accompanied by the decreased protein level of forkhead box O3 (FOXO3) in macrophages. The mechanistic dissection showed that Pg lipopolysaccharide (LPS) evoked macrophage oxidative stress via the TLR4 signaling pathway, which subsequently activated MAPK/ERK-mediated FOXO3 phosphorylation and following degradation. While the gingipains, a class of proteases produced by Pg, could effectively hydrolyze FOXO3 in the cytoplasm of macrophages. Both of them decreased the nuclear level of FOXO3, followed by the release of histone deacetylase 2 (HDAC2) from the macrophage scavenger receptor 1 (Msr1) promoter, thus promoting Msr1 transcription. This enhanced MSR1-mediated lipid uptake further amplified oxidative stress-induced necroptosis in lipid-laden macrophages. In summary, Pg exacerbates macrophage oxidative stress-dependent necroptosis, thus enlarges the atherosclerotic plaque necrotic core and ultimately promotes plaque destabilization.

Transcriptional signatures of endothelial cells shape immune responses in cardiopulmonary health and disease

The cardiopulmonary vasculature and its associated endothelial cells (ECs) play an essential role in sustaining life by ensuring the delivery of oxygen and nutrients. Beyond these foundational functions, ECs serve as key regulators of immune responses. Recent advances in single-cell RNA sequencing have revealed that the cardiopulmonary vasculature is composed of diverse EC subpopulations, some of which exhibit specialized immunomodulatory properties. Evidence for immunomodulation includes distinct expression profiles associated with antigen presentation, cytokine secretion, immune cell recruitment, translocation, and clearance - functions critical for maintaining homeostasis in the heart and lungs. In cardiopulmonary diseases, ECs undergo substantial transcriptional reprogramming, leading to a shift from homeostasis to an activated state marked by heightened immunomodulatory activity. This transformation has highlighted the critical role for ECs in disease pathogenesis and their potential as future therapy targets. This Review emphasizes the diverse functions of ECs in the heart and lungs, particularly adaptive and maladaptive immunoregulatory roles in cardiopulmonary health and disease.

Sentinel Lymph Node Mapping in Esophageal Cancer: Current Status and Future Directions

OBJECTIVE

This review provides a comprehensive discussion about the importance of adequate lymphadenectomy, its anatomic and oncologic significance, principles and rationale of sentinel lymph node mapping, current evidence stratified by tracer substrate, challenges, and future directions. Esophageal cancer has one of the worst cancer-related survival rates, and nodal status is the single most significant prognostic factor. Submucosal penetration generally demands esophagectomy, often following neoadjuvant therapy in the presence of deeper extension. Guidelines recommend resecting ≥15 lymph nodes. Variability in surgical approach and dissection in concert with aberrant esophageal lymphatic anatomy make adequate lymphadenectomy difficult.

METHODS

A narrative review was conducted to explore existing literature regarding lymphadenectomy with its requisite anatomic and oncologic significance in esophageal cancer, as well as the rationale for and present state of sentinel lymph node mapping stratified by substrates. Tables and figures were constructed by the authors using Microsoft Office applications and Biorender software, respectively.

RESULTS

Sentinel lymph node mapping exploits the tumoral lymphatic network to identify the nodes most prone to metastasis, directing further dissection. Targeting sentinel lymph nodes with dyes, radiotracers, or hybrid tracers can assist surgeons with lymphadenectomy, potentially improving staging accuracy and personalizing care to individual anatomy.

CONCLUSIONS

While this approach would benefit from larger studies and long-term data, early evaluations suggest improved detection of metastases outside the en bloc field without significantly increasing morbidity.

Evaluating the quality of online resources for patient education on robotic esophagectomy

Robotic approaches have gained popularity in recent years, with multiple studies showing improved short- and long-term outcomes with this technique for esophagectomy. Educational resources should be assessed to ensure patients are knowledgeable about the treatment modalities that are available. Our aim is to evaluate whether online content is a reliable source of patient educational material for robotic esophagectomy. A YouTube query was performed for: "Robot Assisted Minimally Invasive Esophagectomy." The first 60 videos were evaluated by two independent reviewers and scored using the DISCERN tool. Of the 60 videos reviewed, 48 (80%) were included. The average DISCERN score for the videos was 1.3 ± 0.57 (SD), with a score > 3 being good for patient education and ≤ 3 being poor. The content available on YouTube for education about robotic esophagectomy is better suited for surgical education. This underscores a significant opportunity to improve patient education resources for the betterment of shared decision making.

Subtotal Gastrectomy for Clinical Stage I Remnant Gastric Cancer

BACKGROUND

Subtotal gastrectomy (SG) is a surgical option for early remnant gastric cancer (RGC). However, reports evaluating the feasibility and oncological safety of SG for RGC are limited. Here, we aimed to evaluate the short- and long-term outcomes of SG for RGC.

METHODS

We conducted a multi-institutional retrospective cohort study and compared the outcomes between SG and completion gastrectomy (CG) of patients with clinical stage I RGC. The short- and long-term outcomes, body weight change, and serum albumin level at 1 year postoperatively were evaluated.

RESULTS

Twenty-two and 202 patients in the SG and CG groups, respectively, were included in the analysis. The risk ratios (95% confidence interval [CI]) were 0.90 (0.27, 2.22) and 0.51 (0.33, 2.47) for the overall and severe complications, respectively. No anastomotic leakage was observed in the SG group, while 6.4% of the CG group had anastomotic leakage (p = 0.62). The 3-year relapse-free survival rates were 79.8% and 78.8% in the SG and CG groups, respectively (hazard ratio [95% CI], 0.87 [0.31, 2.40]; p = 0.80). The median body weight changes at 1 year postoperatively from the preoperative level were significantly less in the SG group (96.4% and 90.4% in the SG and CG groups, respectively; p = 0.021), and the median serum albumin changes at 1 year postoperatively were + 0.01 and -0.04 g/dL, respectively (p = 0.551).

CONCLUSION

SG might be one of the potential options for clinical stage I RGC, if the proximal margin is secured.

Smart Silk-Based In Situ Sol-Gel Modulates Rectal Microenvironment for Effective Ulcerative Colitis Alleviation

Ulcerative colitis (UC) is a chronic inflammatory bowel disease, with untreated cases often progressing to colorectal cancer. Current treatments aim to induce inflammatory remission but often neglect the surrounding microenvironment, which significantly impairs mucosal healing and contributes to treatment failures. This study presents a novel silk fibroin-based fucoidan (SFU) in situ rectal gel, with sol-gel transition confirmed through rheological analysis under physiological pH and temperature conditions. The SFU gel exhibits strong antioxidant activity, achieving a DPPH radical scavenging rate of 73.3 ± 1.52%. The gel efficiently reduces reactive oxygen species (ROS) and nitric oxide (NO) production, demonstrating its reliable antioxidant effects. In a DSS-induced UC mouse model, SFU effectively alleviates colitis symptoms, including weight loss and disease activity index (DAI) reduction, with improved stool consistency and reduced rectal bleeding. Moreover, SFU therapy reprograms macrophages from proinflammatory M1 to anti-inflammatory M2 phenotypes, significantly lowering IL-6 and TNF-α levels, suggesting anti-inflammatory properties. Furthermore, SFU increased tight junction proteins Occludin-1 and ZO-1, indicating gut mucosal barrier integrity. SFU treatment restores goblet cells and mucin production while preventing fibrosis, demonstrating its potential as a natural therapy for UC treatment.

A comparison of postoperative outcomes between robotic-assisted and laparoscopic-assisted total gastrectomy: a comprehensive meta-analysis and systematic review

BACKGROUND

The application of robot-assisted technology in gastric cancer surgery is gradually gaining attention from surgeons. In this meta-analysis, our main objective was to assess whether robot-assisted techniques are more advantageous than laparoscopic-assisted technology in total gastrectomy.

METHODS

We searched Pubmed, Embase, Web of Science, and Cochrane Library databases for clinical studies published before October 2023 comparing robotic-assisted total gastrectomy (RATG) and laparoscopic-assisted total gastrectomy (LATG) for gastric cancer. Non-clinical studies, data unavailability, or fewer than 50 included cases were excluded. The Newcastle-Ottawa Scale was used to assess the risk of bias by determining the quality of the observational studies. Statistical meta-analysis and drawing were performed using the Software Review Manager version 5.3 and Stata version 16.0. P < 0.05 was considered significant.

RESULTS

Nine studies that included 1,864 patients with gastric cancer were included, published between 2012 and 2023. The results of the analysis showed that RATG has advantages in the following aspects: intraoperative blood loss was 17.69 ml lower in the RATG group than in the LATG group (WMD: -17.69,95% CI:-20.90 ∼ -14.49; P < 0.05); In terms of the number of resected lymph nodes, the RATG group had 2.65 more than the LATG group (WMD: 2.65,95% CI:0.88 ∼ -4.42); P < 0.05); the time to start liquid and postoperative hospital stays were 0.62 and 0.90 days shorter in the RATG group than in the LATG group, respectively (WMD: -0.62,95%CI: -1.06 ∼ -0.19; P < 0.05), (WMD: -0.90,95%CI: -1.43 ∼ -0.37; P < 0.05)); the incidence of major complications and pancreas fistula in the RATG group was 0.59% and 0.17% lower than in the LATG group, respectively (OR: 0.59,95% CI: 0.38 ∼ 0.93; P < 0.05), (OR: 0.17,95% CI: 0.03 ∼ 0.94; P < 0.05). However, the analysis showed that the operative time in the RATG group was 30.96 min longer than in the LATG group (WMD: 30.96,95% CI: 21.24 ∼ 40.69; P < 0.05).

CONCLUSIONS

Based on the results of this meta-analysis, we concluded that robotic-assisted technology may be a worthwhile technique to apply in the surgical treatment of total gastrectomy. However, this meta-analysis has the limitations that the included studies were all non-randomized controlled trials and published in Asian countries, and more high-quality randomized controlled trials are needed for further validation in the future.

THE REGISTERED NAME AND REGISTRATION NUMBER

The study protocol for this meta-analysis is registered on the PROSPERO website under registration number CRD42024500512.

Artificial intelligence as a predictive tool for gastric cancer: Bridging innovation, clinical translation, and ethical considerations

With gastric cancer ranking among the most prevalent and deadly malignancies worldwide, early detection and individualized prognosis remain essential for improving patient outcomes. This letter discusses recent advancements in artificial intelligence (AI)-driven predictive tools for gastric cancer, emphasizing a computed tomography-based radiomic model that achieved a predictive accuracy of area under the curve of 0.893 for treatment response in advanced cases undergoing neoadjuvant immunochemotherapy. AI offers promising avenues for predictive accuracy and personalized treatment planning in gastric oncology. Additionally, this letter highlights the comparison of these AI tools with traditional methodologies, demonstrating their potential to streamline clinical workflows and address existing gaps in risk stratification and early detection. Furthermore, this letter addresses the ethical considerations and the need for robust clinical-AI collaboration to achieve reliable, transparent, and unbiased outcomes. Strengthening cross-disciplinary efforts will be vital for the responsible and effective deployment of AI in this critical area of oncology.

Performing robot-assisted minimally invasive esophagectomy for patients with a narrow mediastinum and left-shifted esophagus for esophageal squamous cell carcinoma presents further challenges

BACKGROUND

Several studies have compared robot-assisted minimally invasive esophagectomy (RAMIE) with conventional minimally invasive surgery (C-MIE). However, the anatomical factors that may make certain patients more suitable for RAMIE remains unclear. This study compared the surgical outcomes of RAMIE with those of C-MIE in patients with narrow mediastinum and left-shifted esophagus.

METHODS

Between January 2017 and December 2023, 260 patients with esophageal squamous cell carcinoma (ESCC) who underwent MIE (C-MIE or RAMIE) at Kobe University Hospital were included in the study. We developed a new index to assess the narrow mediastinum and left-shifted esophagus at the tracheal bifurcation level using computed tomography imaging. Cox proportional hazards regression analyses were performed to identify the prognostic factors.

RESULTS

Patients with a narrow mediastinum and left-shifted esophagus had a higher incidence of recurrent laryngeal nerve (RLN) palsy and fewer lymph nodes dissections than other patients (p = 0.026 and p = 0.051, respectively). In the entire cohort, the operative time in the RAMIE group was longer than that in the C-MIE group (< 0.0001). No significant differences in other variables, including RLN palsy, were observed between the two groups. Among patients with narrow mediastinum and left-shifted esophagus, RAMIE was associated with longer operative time and fewer lymph nodes dissected from the left and right sides of the upper mediastinum compared to C-MIE (p < 0.0001, 0.0001, and 0.0001, respectively). Regarding the RLN palsy, there was no significant difference (p = 0.79).

CONCLUSIONS

There are challenges in performing RAMIE in patients with a narrow mediastinal and left-shifted esophagus. Therefore, establishing an effective procedure for these patients is important.

The gut microbiota and aging: interactions, implications, and interventions

The human microbiota, a complex ecosystem of microorganisms inhabiting various body sites, particularly the gut, plays a crucial role in maintaining health and influencing disease susceptibility. Dysbiosis, characterized by alterations in microbial composition and diversity, has been implicated in numerous diseases, including those associated with aging. This review examines the complex relationship between gut microbiota and aging, highlighting the age-associated gut microbiota alterations, the factors contributing to these changes, the links between microbiota and age-related diseases, and the potential of interventions targeting the microbiome to extend lifespan and improve health outcomes in the elderly. Further research is needed to unravel the intricate mechanisms underlying the interplay between the microbiome and aging, paving the way for innovative strategies to promote healthy aging.

Time-varying mortality risk after gastrointestinal surgery complicated by postoperative infections: a Danish Nationwide study of 859,766 patients

PURPOSE

Postoperative infections are associated with increased mortality risk, but it is unclear if this risk increase persists over time. This study aims to estimate mortality risk associated with postoperative infections at different time-points within the first postoperative year in a nationwide cohort of gastrointestinal surgery patients.

METHODS

We included all individuals residing in Denmark who underwent gastrointestinal surgery between 1996 and 2018 and were alive at postoperative day 30. For different time-intervals during the one-year follow-up, we calculated mortality rates and cumulative incidences of death for patients with and without 30-day postoperative infections. Time-varying Cox regression analyses estimated the relative mortality risk associated with postoperative infection exposure.

RESULTS

Of 859,766 patients (female:49.2%; median age:51 years), 25,126 (2.9%) had at least one 30-day postoperative infection. In patients with or without infections, cumulative incidences of death between postoperative days 30-365 were 13.5% versus 4.7%. Adjusted hazard ratios (HRs) for mortality from postoperative days 30, 91, 181, and 271 until end of follow-up (until postoperative day 365) were 2.25(95% CI:2.13-2.38), 1.88(1.74-2.04), 1.44(1.29-1.62), and 1.11(1.00-1.28) for any postoperative infection compared to no infection (ptime-interaction<0.001). The adjusted HRs for mortality for postoperative days 30-365 in patients exposed to different postoperative infection types were: sepsis: 4.38(3.90-4.93), pneumonia: 2.60(2.37-2.85), urinary tract infection: 1.26(1.05-1.52), surgical site infection: 1.16(1.04-1.30).

CONCLUSION

Compared to patients with no infection, patients exposed to 30-day postoperative infections after gastrointestinal surgery had a 2.3-fold risk of mortality at postoperative days 30, and the relative risk of mortality attributed to infection exposure gradually diminished over time.

Laparoscopic vs robot-assisted gastrectomy in gastric cancer patients with prior abdominal surgery: a propensity-matched analysis

No studies have compared the efficacy of laparoscopic gastrectomy (LG) and robot-assisted gastrectomy (RG) for gastric cancer (GC) patients with a history of abdominal surgery (HAS). This is the first study in this field to identify complication-related factors and compare survival outcomes using propensity score matching (PSM) and a competing risk model (CRM). A retrospective cohort study was conducted on GC patients with HAS who underwent radical LG or RG. PSM was applied to achieve baseline balance. Univariate and multivariate regression analyses were performed to identify factors independently associated with complications. CRM adjusted by inverse probability of censoring weighting (IPCW) was used to analyze overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS) across different TNM stages. PSM with a 3:1 ratio ensured baseline balance while minimizing sample loss (LG n = 87, RG n = 29). RG was associated with a significantly longer surgery duration but a lower incidence of overall and Clavien-Dindo (CD) grade ≥ 2 complications. Multivariate analysis identified RG (OR, 95% CI: 0.02, 0.01-0.15), surgery duration (OR, 95% CI: 1.01, 1.00-1.01), and lymphadenectomy extent (OR, 95% CI: 2.81, 1.16-7.25) as independent factors associated with overall complications. Likewise, RG (OR, 95% CI: 0.06, 0.01-0.38), surgery duration (OR, 95% CI: 1.01, 1.00-1.02), and tumor size (OR, 95% CI: 1.02, 1.00-1.04) were independently associated with CD grade ≥ 2 complications. Kaplan-Meier analyses based on IPCW-adjusted CRM showed no significant differences in OS, CSS, and DFS between RG and LG across TNM stages. RG may efficiently reduce complications compared to LG but offers no survival benefit, suggesting a potential advantage in perioperative safety for GC patients with HAS.

Short-term outcomes of minimally invasive gastrectomy in population with obesity versus population without obesity: the obesity paradox

This study aims to compare the short-term outcomes after minimally invasive gastrectomy between obese and non-obese population. Our analysis included data of 713 patients from ten departments of surgery. They were divided in non-obese group and obese group with 617 and 96 patients respectively. Significant differences were found in terms of mortality at 90 days (obese: 0 vs non-obese: 27, p = 0.037). Intraoperative data showed no significant differences in terms of conversion (obese: 4 vs non-obese: 43, p = 0.303). About postoperative complications, significant differences between the two groups were found only in terms of surgical infection (obese: 13 vs non-obese: 38, p = 0.009). About oncological outcomes, no differences were found about retrieved lymph nodes (obese: 30.71 ± 18.44 vs non-obese: 32.93 ± 17.62, p = 0.596) and about surgical radicality (R0) (obese:94 vs non-obese:594, p = 0.415). Obesity doesn't worsen postoperative outcomes and minimally invasive gastrectomy in obese patients is related to a lower postoperative mortality.

Laparoscopic versus open distal gastrectomy with d2 lymphadenectomy in treatment of locally T4A gastric cancer: the protocol of a randomized controlled trial

BACKGROUND

Gastric cancer (GC) remains one of the leading causes of cancer-related mortality worldwide. While laparoscopic gastrectomy (LG) has been widely adopted for early and locally advanced gastric cancer (AGC), its safety and oncological efficacy in T4a GC remain unclear. To date, no randomized controlled trials have specifically examined the role of LG in the treatment of T4a GC. This study aims to provide robust evidence comparing the short- and long-term outcomes of laparoscopic distal gastrectomy (LDG) versus open distal gastrectomy (ODG) in resectable T4a GC.

METHODS

This is a phase III, randomized controlled, non-inferiority trial. Patients with clinical T4a GC (cT4aN0-3M0) suitable for distal gastrectomy with D2 dissection will be randomly assigned in a 1:1 ratio to undergo either LDG or ODG. A total 240 patients (120 each group) are required to statistically show non-inferiority of the LDG with respect to the primary end-point, 3-years disease-free survival (DFS). Secondary endpoints include morbiity, mortality, postoperative recovery, and quality of life.

DISCUSSION

This study is the first prospective randomized trial specifically designed to compare laparoscopic and open approaches for T4a GC. By standardizing surgical techniques and ensuring experienced surgeons perform the procedures, this trial aims to establish whether LDG can provide equivalent oncological outcomes while reducing perioperative morbidity and enhancing postoperative recovery. The findings will provide high-quality evidence to inform future guidelines and clinical decision-making in the management of T4a gastric cancer.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov (NCT04384757), version 6. Registration Date: 08/05/2020.

The bidirectional interplay between gut dysbiosis and surgical complications: A systematic review

BACKGROUND

The gut microbiome critically influences diverse aspects of physiology and surgical recovery. Conversely, surgery alters the microbiome, potentially predisposing to complications. We aimed to clarify the bidirectional interaction between surgery and gut dysbiosis.

METHODS

On December 22nd, 2024, a systematic search of the Cochrane Library, PubMed, VHL, and WOS was completed. Relevant studies were assessed for risk of bias using STROBE and CONSORT guidelines.

RESULTS

Thirty studies, with 2500+ participants experiencing diverse procedures and complications, were incorporated. Although specifics varied, dysbiosis correlated with surgery and its complications. Patients with complications had more harmful bacteria and fewer beneficial bacteria. In some studies, probiotics reduced complications.

CONCLUSION

Gut dysbiosis is tied to postoperative complications in a complex, bidirectional relationship. Patients with surgical complications may have fewer beneficial and more pathogenic bacteria both before and after surgery. Early identification of dysbiosis and probiotic administration could predict or even reduce postoperative complications.

Clinical value of preoperative circulating tumor DNA before surgery in patients with esophageal squamous cell carcinoma

INTRODUCTION

A precise preoperative tumor monitoring method that reflects tumor burden during neoadjuvant treatment is required to guide individualized perioperative treatment strategies for esophageal squamous cell carcinoma (ESCC). This study examined the clinical significance of preoperative circulating tumor DNA (ctDNA) in the plasma of patients undergoing neoadjuvant chemotherapy (NAC) followed by esophagectomy.

MATERIALS AND METHODS

Plasma samples were collected longitudinally for ctDNA analysis as well as genomic DNA from primary lesions from patients with histologically confirmed ESCC who received neoadjuvant chemotherapy (NAC) followed by subtotal esophagectomy. Next-generation sequencing was used to identify mutations in both the plasma and primary tumors. We evaluated the relationship between ctDNA alterations and recurrence in patients with locally advanced ESCC.

RESULTS

Pretreatment samples from 25 patients (100 %) showed the same mutations in both ctDNA and primary tumors; therefore, they were classified as ctDNA-positive before treatment. In the cohort of 25 patients analyzed, those who tested positive for ctDNA after NAC had a significantly higher risk of recurrence; the 36-month recurrence-free survival rates were 92 % for ctDNA-negative patients and 8 % for ctDNA-positive patients (p < 0.001).

CONCLUSIONS

Preoperative ctDNA status may be a promising prognostic biomarker that can be assessed before surgery in patients with ESCC who received NAC. Expanded cohort validation will allow for more personalized multidisciplinary treatment approaches for ESCC tailored to ctDNA analysis.

Comparison of short- and long-term outcomes of robotic versus laparoscopic gastrectomy for locally advanced gastric cancer after neoadjuvant therapy: a high-volume center retrospective study with propensity score matching

BACKGROUND

Although neoadjuvant therapy (NAT) for advanced gastric cancer (AGC) can benefit patient survival, few studies have compared the short- and long-term outcomes of robotic and laparoscopic gastrectomy for AGC after NAT.

METHODS

The clinical data of 321 AGC patients who received NATs and who underwent robotic gastrectomy (RG, n = 109) or laparoscopic gastrectomy (LG, n = 212) between May 2017 and September 2022 were collected and analyzed retrospectively at our center. After propensity score matching (PSM) for 1:1 matching to eliminate bias, both groups had 106 cases. Short-term clinical outcomes and long-term survival-related indicators were compared between the two groups of patients.

RESULTS

A total of 212 patients were included in the groups after matching. There were fewer overall complications (13.2% vs. 28.3%, P = 0.007) and surgical complications (8.5% vs. 17.9%, P = 0.043) in the RG group than in the LG group. Compared with the LG group, the RG group had more harvested overall lymph nodes (35.25 ± 4.99 vs. 31.45 ± 6.31, P < 0.001) and more suprapancreatic lymph nodes (13.12 ± 4.38 vs. 10.05 ± 4.13, P < 0.001). Patients in the RG group had significantly shorter surgery times (217.62 ± 47.49 vs. 267.25 ± 70.68, P < 0.001) and less blood loss (46.51 ± 27.02 vs. 70.75 ± 37.25, P < 0.001) than patients in the LG group. The RG group had significantly faster bowel function recovery, earlier liquid diet, and shorter hospital stay. Compared with LG, RG had a better 3-year RFS (75.5% vs. 62.3%, P = 0.017).

CONCLUSION

Compared with laparoscopic surgery, robotic surgery significantly increased the number of lymph node dissected, reduced intraoperative blood loss, and postoperative surgical complications rate. Although RG did not statistically improve 3-year overall survival, there was a significant improvement in RFS and could be an alternative surgical method for GC patients after NAC.

Global trends and insights of telesurgery research: a bibliometric analysis of publications since the 21st century

BACKGROUND

In recent years, telesurgery has shown a rapid development trend as an innovative surgical technique, and been applied to the clinical treatment of various tumor diseases. However, the current research on telesurgery is still relatively fragmented, lacking a systematic summary of its development and future directions. Addressing these limitations is crucial for advancing the application of this novel surgical technology.

METHODS

This bibliometric study of publications related to telesurgery that were indexed in the Web of Science Core Collection from 2000 to 2024. VOSviewer, CiteSpace, and Bibliometrix were used to analyze and visually represent the gathered data, and the relevant content was presented according to the BIBLIO guidelines.

RESULTS

We researched 565 publications across 269 journals authored by 2422 individuals affiliated with 917 institutions spanning 62 countries. Notably, the United States leads in the number of publications, with China also making noteworthy contributions. Kyushu University and the University of Washington emerge as prominent institutions in terms of research output within this domain. Analysis of document co-occurrence and co-citation reveals that Jacques Marescaux from France holds the top position globally among authors and wields significant influence in this field. Keyword analysis indicates that key future research directions in this area include mitigating latency issues in telesurgery, integrating advanced network communication technologies, and enhancing the performance of telesurgical robots. Furthermore, ethical and legal issues associated with telesurgery may emerge as critical challenges to be addressed for its further expansion and application.

CONCLUSION

This research provides an overview of telesurgery research findings, encompassing the evolution of research priorities in telesurgery. The study anticipates that the secure implementation and broader adoption of telesurgery will bring more benefits to patients on a global scale.

Robotic and laparoscopic gastrectomy for gastric cancer: comparative insights into perioperative performance and three-year survival outcomes

BACKGROUND

The primary treatment for gastric cancer (GC) is surgical resection, particularly for locally advanced cases. While laparoscopic gastrectomy (LG) has shown short- and long-term benefits, robotic gastrectomy (RG) offers enhanced precision and may lead to better outcomes, especially in advanced-stage disease.

METHODS

This retrospective study analyzed data from 1538 patients with pathological Stage I-III GC who underwent RG or LG between 2014 and 2021. Propensity score matching created 466 matched pairs. Perioperative outcomes, 3 year overall survival (OS), 3 year recurrence-free survival (RFS), and recurrence patterns were compared between RG and LG.

RESULTS

RG demonstrated significantly shorter operative time (235.5 vs. 242.5 min, p = 0.001), less blood loss (19.1 vs. 33.4 ml, p < 0.001), and shorter hospital stay (7.9 vs. 9.7 days, p < 0.001). Overall complications did not differ significantly (p = 0.183), but RG had lower rates of anastomotic leakage (p = 0.045) and pancreatic fistula (p = 0.024). No significant differences in OS were observed in the overall cohort or by stage. Similarly, RFS showed no significant differences in the overall cohort (3 year RFS: RG 86.81% vs. LG 83.04%, p = 0.1347). By stage, no differences were found in stage I or II, but in stage III, RG showed better 3 year RFS (67.52% vs. 52.97%, p = 0.0424). RG also had lower recurrence rates (9.0% vs. 14.8%, p = 0.0061), with fewer liver (p = 0.0069) and lymph node metastases (p = 0.0223).

CONCLUSION

RG demonstrated superior short-term outcomes and comparable three-year OS to laparoscopic gastrectomy, with improved three-year RFS and reduced recurrence in Stage III, likely facilitated by earlier adjuvant chemotherapy initiation.

Young pediatric surgeons without endoscopic surgical skill qualification safely perform advanced endoscopic surgery under the supervision of expert qualified surgeons

BACKGROUND

Young pediatric surgeons should receive adequate training in various minimally invasive surgeries (MIS). However, it is essential to maintain patient safety and outcomes during the learning process. In Japan, the endoscopic surgical skill qualification (ESSQ) system in pediatric surgery was initiated by the Japan Society for Endoscopic Surgery (JSES) in 2009 to objectively evaluate the skill of endoscopic surgeons. This study compared perioperative outcomes between pediatric surgeons with ESSQ qualifications and those without (non-ESSQ).

METHODS

We retrospectively reviewed the medical records of children with choledochal cyst (CC), lobectomy, and biliary atresia (BA) who underwent MIS at our hospital from 2013 to 2023. We assessed the performance of nonqualified surgeons assisted by supervisors with ESSQ qualifications.

RESULTS

This study included the records of 101 surgical cases with CC (operated by ESSQ: 36, non-ESSQ: 65), 78 patients with BA (operated by ESSQ: 35, non-ESSQ: 43), and 67 patients with lobectomy (operated by ESSQ: 31, non-ESSQ: 36). For the CC and lobectomy groups, there were no significant differences in operating time, blood loss, and postoperative complications (PO) between the ESSQ and non-ESSQ groups. In BA, the operative times for the ESSQ and non-ESSQ groups were 310 and 377 min, respectively (p = 0.001). Furthermore, no significant differences were observed in blood loss, PO, jaundice-clearance ratio, and jaundice-free survival rate with the native liver between the two groups.

CONCLUSION

The results indicate that young pediatric surgeons can safely perform MIS while practicing under the supervision of experienced ESSQ-qualified surgeons.

Current trends and challenges in minimally invasive surgical treatment for gynecologic cancers in Japan: a cancer statistics report

Minimally invasive surgery (MIS) for gynecologic cancers, which includes laparoscopic and robotic approaches, has seen significant growth in Japan over the past decade. While offering numerous benefits, including reduced postoperative pain and shorter hospital stays, its rapid adoption has also highlighted several challenges, particularly in the management of severe surgical adverse events and disparities in training and access to technology. This article explores the current trends in MIS adoption in Japan, focusing on laparoscopy and robotic surgery, their benefits and limitations, the regulatory and certification frameworks established by the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy, and future directions for ensuring safety and efficacy in gynecologic oncology surgery.

Efficacy of a linear stapler in entry hole closure during overlap anastomosis in minimally invasive gastrectomy

BACKGROUND

Overlap anastomosis is widely used in gastrointestinal reconstruction during minimally invasive gastrectomy. The entry hole of the anastomosis is typically closed with hand-sewn sutures because of concerns about stenosis. This study aimed to compare the efficacy of linear stapler (LS) closure with that of hand-sewn closure of the entry hole in overlap anastomosis.

METHODS

We included 172 patients who underwent overlap anastomosis during laparoscopic or robot-assisted total gastrectomy (TG, Roux-en-Y) or distal gastrectomy (DG, Roux-en-Y/Billroth II) between February 2020 and September 2024. The patients were divided into two groups based on the method of entry hole closure: the suturing group (S group) and the LS group. Surgical outcomes were retrospectively analyzed.

RESULTS

There were no significant differences in patient characteristics or tumor staging between the two groups. TG was performed in 46 and 17 patients in the S and LS groups, respectively, whereas DG was performed in 41 and 68 patients in the S and LS groups, respectively. In TG patients, there was no significant difference in operative time, but the esophageal-jejunal overlap anastomosis time was significantly shorter in the LS group (38.3 vs. 20.5 min, P < 0.001). The incidence of postoperative complications was similar in both groups, and no cases of stenosis were observed in the LS group. In DG patients, the operative time and gastric-jejunal overlap anastomosis time were significantly shorter in the LS group (294 min vs. 253 min, P = 0.002; 28.5 vs. 9.0 min, P < 0.001). The length of postoperative hospital stay was significantly shorter in the LS group (13 vs. 11 days, P = 0.01).

CONCLUSION

Using an LS to close the entry hole in an overlapping anastomosis during minimally invasive gastrectomy can reduce the anastomosis time and may be a safe option without increasing the risk of stenosis.

The mentoring effects of learning curve of total extraperitoneal hernioplasty: the CUSUM analysis of the pioneer and second-generation surgeon

BACKGROUND

Most studies demonstrated that the learning curve of total extraperitoneal hernioplasty (TEP) is around 30-80 cases. All these studies were performed by a single surgeon who had little or no experience of TEP repair before. However, with mentoring by experienced surgeon, the second-generation surgeon may get more familiar with the anatomy and procedures of TEP than the pioneer surgeon. Besides, the surgical caveats would be further understood and pitfalls avoided by mentoring with the pioneer surgeon. The aims of this study were to investigate the effects of mentoring by pioneer surgeon to the second-generation surgeon in the TEP operation by comparing the learning curve and complications of pioneer and second-generation surgeon.

METHODS

We retrospectively reviewed our TEP cases performed by the two surgeons, the pioneer surgeon and the second-generation surgeon, in general surgery department in Chang Gung Memorial Hospital, Keelung division. The reviewed period was between January 2016 and December 2021. The pioneer surgeon performed the TEP surgery by himself. The second-generation surgeon attended 20-30 cases of TEP done by pioneer surgeon. Then, the pioneer surgeon mentored the second-generation surgeon's first 10 TEP cases. By comparing the operation time, the intraoperative and post-operative complications, cumulative sum (CUSUM) learning curve was used for analysis.

RESULTS

The CUSUM analysis reveals that the learning curve of TEP is around 45 procedures in the pioneer surgeon and 30 procedures in the second-generation surgeon. The median operation time in pioneer surgeon and second-generation surgeon is 103.5 vs 90 min (p = 0.03). The overall intraoperative and post-operative complications between pioneer and second-generation surgeon reveal no significant difference. After crossing the learning curve, the operation time of pioneer surgeon and the second-generation surgeon decreased significantly, from 114 to 93 min (p = 0.008) and from 103 to 87.2min (p = 0.032), respectively. However, there was no significant difference in the overall post-operative complications.

CONCLUSIONS

By mentoring with the pioneer surgeon, the second-generation surgeon may achieve the learning curve quicker than the pioneer surgeon in terms of operation time. After reaching the learning curve, the operation time before and after learning curve reveal significant different in both surgeons while the overall post-operative complications reveal no significant different.

Possibility of preventing intra-abdominal infection by lymph node mapping with indocyanine green in robotic gastrectomy

BACKGROUND

Intra-abdominal infection can be an onerous and fatal complication of radical gastrectomy for gastric cancer. High drain amylase levels are closely related to pancreatic damage and intra-abdominal infection. We aimed to investigate whether robotic radical gastrectomy with lymph node mapping by indocyanine green tracer reduces drain amylase levels.

METHODS

Between March 2019 and July 2024, patients at our institution with clinical tumor stage cT1-T4a, N0/+, M0, and possibly treatable gastric cancer were enrolled in this study and divided into the indocyanine green group or the non-indocyanine green group based on the use of indocyanine green. One day before surgery, the patients in the indocyanine green group underwent endoscopic peritumoral injection of indocyanine green into the submucosa. Drain amylase levels on postoperative days 1 and 3, postoperative intra-abdominal infection, and perioperative outcomes were compared between the 2 groups.

RESULTS

There were no significant differences in patient background and pathologic factors between the 2 groups. Drain amylase levels on postoperative days 1 and 3 were significantly lower in the indocyanine green group than in the non-indocyanine green group, and postoperative hospital stay was shorter. The incidence of intra-abdominal infection was also significantly lower in the indocyanine green group than in the non-indocyanine green group. However, multivariate analysis of intra-abdominal infection showed a drain amylase level of 200 IU/L or higher on postoperative day 3 to be an independent risk factor for postoperative intra-abdominal infection, whereas indocyanine green use was not.

CONCLUSION

This study showed the clinical usefulness of robotic radical gastrectomy with lymph node mapping by indocyanine green. This procedure can reduce drain amylase levels and consequently may reduce the incidence of intra-abdominal infection.

Risk factors for pneumonia after endoscopic laryngopharyngeal surgery in cases with prior esophageal cancer treatment

Background and Study Aims

Endoscopic laryngopharyngeal surgery is an effective treatment for superficial laryngopharyngeal cancer, particularly in cases with prior esophageal cancer treatment. Despite its frequent application, reports on the risk factors for postoperative complications are limited. This study aimed to identify the risk factors for pneumonia after endoscopic laryngopharyngeal surgery and to examine the variations in pneumonia incidence among the types of prior esophageal cancer treatment.

Methods

Patients who had a history of esophageal cancer treatment and subsequently underwent endoscopic laryngopharyngeal surgery for superficial pharyngolaryngeal cancer were retrospectively analyzed. We examined the association between postoperative pneumonia and several factors, including number of lesions; diameter of the resected lesion; and type of previous esophageal cancer treatment, such as endoscopic submucosal dissection, chemoradiotherapy, and esophagectomy.

Results

The study included 79 patients who had a mean age of 67.4 years. Postoperative pneumonia occurred in 16.4%. Multivariate analysis showed that the pneumonia incidence significantly increased in cases with multiple lesions (OR 4.794, 95% CI 1.133-20.288, p = 0.033) and larger diameter of the resected lesion (OR 7.047, 95% CI 1.791-27.730, p = 0.005). Importantly, compared with other treatments, prior esophagectomy for esophageal cancer did not increase the pneumonia incidence.

Conclusions

Multiple lesions and larger lesion diameter were the significant predictors of postoperative pneumonia. Moreover, endoscopic laryngopharyngeal surgery can be safely performed even in patients who have previously undergone esophageal cancer surgery, although careful monitoring remains necessary.

Rectal Resection with Hysterectomy for Locally Advanced Rectal Cancer Using the hinotori Surgical Robot System: The First Ever Case Report

The number of reports of robotic surgery for rectal cancer with combined resection of other organs is increasing gradually, with most procedures performed using the da Vinci Surgical System. The hinotori Surgical Robot System, developed in Japan, was approved for gastrointestinal surgery and gynecology in 2022. Here, we report the first case of en-bloc rectal resection with hysterectomy using the hinotori Surgical Robot System. A 77-year-old woman was referred to our institution with a diagnosis of rectal cancer (cT4bN1bM1a), with uterine invasion and a resectable liver metastasis. We performed rectal resection with total hysterectomy and bilateral salpingo-oophorectomy using the hinotori Surgical Robot System. Two surgical teams, a gastroenterological team and a gynecological team, performed en-bloc resection of the rectum and uterus. Because of in-depth consultation between the teams, the operation was performed safely with no unplanned additional ports, robotic arm interference or arm collision with the assistant surgeon. Including the preceding stoma closure, the operative time was 473 minutes, and blood loss was 60 mL. The patient experienced no complications ≥ Clavien-Dindo classification grade III. Robot-assisted extended surgery for locally advanced rectal cancer using the hinotori Surgical Robot System can be performed safely, which may lead to an expanded treatment option in the future.

Modified Devine exclusion for unresectable gastric cancer: a bridge from palliative to curative treatment

Progressive advances in cytotoxic systemic therapy have significantly improved survival and quality of life in oncology, particularly in gastric carcinoma, allowing the reconsideration of surgical strategies for patient benefit. We present a case of a female patient in her 70s with locally advanced, unresectable gastric carcinoma causing malignant gastric outlet obstruction syndrome, without metastasis. Following multidisciplinary discussion, the patient underwent palliative partial stomach-partitioning gastrojejunostomy and systemic therapy with the EOX regimen. At 12 months, the patient showed sustained clinical, biochemical and radiological responses, maintaining good nutritional status and quality of life. This led to curative intent surgery, during which the tumour was resectable without multiorgan involvement. A subtotal gastrectomy with D2 lymphadenectomy was performed. Pathology confirmed a tubular gastric adenocarcinoma (ypT2N0, R0). Five years postresection, the patient remains disease-free, with excellent general health, good nutrition and quality of life.

Evaluation of the New Robotic Platform "HINOTORI™" in Urologic Robot-Assisted Surgery: From a Comparison with da Vinci® Surgical System in Sacrocolpopexy

Background/Objectives: HINOTORI™ is a robotic-assisted surgical platform developed in Japan. It has been applied in urologic procedures such as robot-assisted radical prostatectomy (RARP) and partial nephrectomy (RAPN). This study aimed to evaluate the clinical performance of HINOTORI™ compared with the da Vinci® surgical system by analyzing outcomes of robot-assisted sacrocolpopexy (RSC) performed by a single skilled surgeon using a uniform surgical procedure. Methods: A total of 125 patients who underwent RSC for pelvic organ prolapse (POP) were analyzed. Surgical outcomes were compared between the HINOTORI™ (h-RSC group) and da Vinci® (d-RSC group) platforms. Evaluated parameters included operative time, robotic console time, anterior compartment dissection time, suture time per stitch, perioperative complications, hospital stay, and POP recurrence. Results: Operative and robotic console times were significantly longer in the h-RSC group (148 vs. 139 min, p < 0.005; 109 vs. 95 min, p < 0.001). Anterior compartment dissection time showed no significant difference (p = 0.58), but suture time per stitch was longer in the h-RSC group (76 vs. 60 s, p < 0.005), possibly due to limited suture-cutting functionality, requiring manual assistance. No significant differences were observed in perioperative complications, hospital stay, and POP recurrence. Conclusions: HINOTORI™ demonstrated surgical precision and safety comparable to the da Vinci® surgical system. It may serve as a viable alternative robotic platform, supporting broader adoption of robot-assisted surgical technologies.

HMGB1 regulates the activation of dendritic cells and CD4+ T cell responses through the modulation of autophagy in bleomycin-induced pulmonary fibrosis

BACKGROUND

The role of HMGB1 in inflammation and autophagy has garnered increasing attention; however, its impact on the activation of dendritic cells (DCs) and autophagy remains unclear. This study aims to explore the effects of HMGB1 on DC activation, autophagy, and its influence on CD4+ T cell responses in a bleomycin-induced pulmonary fibrosis (PF) mouse model.

METHODS

Thirty mice were randomly divided into control and model groups. The model group was established by intratracheal injection of bleomycin to induce PF. Flow cytometry was used to detect DC surface markers, and western blot was employed to assess the expression of autophagy-related protein LC3. Lung DCs and peripheral blood CD14+ monocytes were sorted using magnetic beads and differentiated into M0-DCs, which were then subjected to HMGB1 stimulation experiments to assess activation and cytokine secretion. HMGB1-stimulated or untreated M0-DCs were co-cultured with CFSE-labeled naive CD4+ T cells to evaluate T cell proliferation and differentiation. The effects of HMGB1 on DCs activation, cytokine secretion, and autophagy-related protein expression were assessed after treatment with autophagy regulators.

RESULTS

The model group showed significantly elevated levels of HMGB1 in serum and lung tissues, accompanied by upregulated activation markers of DCs and increased expression of autophagy-related protein LC3. HMGB1 stimulation significantly enhanced the activation of M0-DCs and the secretion of pro-inflammatory cytokines, promoting the proliferation of CD4+ T cells and their differentiation into Th1 and Th17 subsets. Rapamycin, which enhances autophagy, potentiated HMGB1-mediated DC activation, while 3-MA, which inhibits autophagy, suppressed the effects of HMGB1, further influencing CD4+ T cell differentiation.

CONCLUSION

HMGB1 modulates DC autophagy, thereby affecting their activation and immune responses of CD4+ T cells in bleomycin-induced PF. Targeting HMGB1 and the autophagy pathway may provide new strategies for the treatment of PF.

Endothelial Function and Pro-Inflammatory Cytokines as Prognostic Markers in Acute Coronary Syndromes

Background: Endothelial dysfunction and inflammation are associated with the progression of coronary artery disease (CAD) and the pathophysiology of acute coronary syndrome (ACS). We examined the prognostic role of endothelial function and pro-inflammatory cytokines in patients admitted with ACS. Methods: The study population consisted of 864 subjects. From 663 subjects who presented with chest pain, ACS was diagnosed in 460. We additionally recruited 201 consecutive patients with stable CAD. Endothelial function was assessed using flow-mediated dilatation (FMD). Tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6) levels were measured via ELISA. Subjects with ACS were followed up for major adverse cardiovascular events (MACE), defined as cardiovascular death, cardiac arrest, myocardial infarction, stroke, nonfatal stroke, other arterial thrombotic events, and hospitalization due to cardiovascular conditions. Results: There was a stepwise impairment in FMD, logTNF-α, and logIL-6 in patients with chest pain of non-epicardial CAD etiology compared to patients with stable CAD and those with ACS (p < 0.001 for all). Moreover, patients who presented with chest pain had increased odds of ACS in accordance with the increasing levels of TNF-α, IL-6, and impaired FMD (p < 0.05 for all). Interestingly, from all these markers, in patients with ACS, we found that only TNF-α levels above 5.19 pg/mL had a 2.5-times-increased risk of MACE compared to patients with TNF-α levels below 5.19 pg/mL, independently of other confounders. Conclusions: In the current study, we found that patients who presented with ACS had impaired endothelial function and increased levels of IL-6 and TNF-α.

Usefulness of shear-wave elastography for detection of lymph node metastasis in esophageal and gastric cancer

BACKGROUND

Tissue hardness is closely related to disease pathophysiology. Shear-wave elastography (SWE) is a simple and noninvasive ultrasound technique that has been used to evaluate the presence of lymph node metastases and differentiate between benign and malignant tumors.

AIM

To investigate SWE usefulness in measuring lymph node hardness to predict metastasis presence or absence in surgically removed lymph nodes.

METHODS

This observational study obtained data from patients who underwent surgery for esophageal or gastric cancer at Nippon Medical School Hospital. The hardness of the surgically removed lymph nodes was measured using SWE. The lymph nodes with hardness values ≥ 2.2 m/s were considered clinically positive for metastasis, whereas those with lower hardness values were considered clinically negative. The lymph nodes subsequently underwent pathological examination to determine the presence of metastasis, and the SWE results and pathological assessments were compared.

RESULTS

A total of 1077 lymph nodes were evaluated; 18 and 15 cases of esophageal and gastric cancer were identified, respectively. The optimal cutoff value for lymph node size was calculated to be 5.1 mm, and the area under the curve value was 0.74 (95% confidence interval: 0.69-0.84). When limited to a lymph node larger than the cut off value, the SWE sensitivity and specificity for metastasis identification were 0.76 and 0.82, respectively.

CONCLUSION

SWE was useful in detecting lymph node metastases in the upper gastrointestinal tract.

[Effectiveness analysis of 5G remote robotic surgery in pelvic fracture treatment]

Objective

To investigate the effectiveness of 5G remote robotic surgery in the treatment of pelvic fractures.

Methods

A retrospective analysis was conducted on the clinical data of 160 patients with pelvic fractures admitted between July 2023 and June 2024 who met the selection criteria. Among these patients, 80 underwent internal fixation surgery with the assistance of 5G remote robotic surgery (5G group), while 80 received local robotic surgical assistance (control group). Baseline characteristics, including gender, age, body mass index, disease duration, cause of injury, and fracture classification, were compared between the two groups, and no significant difference was found ( P>0.05). The incision length, operation time, intraoperative blood loss, hospital stay, accuracy of screw placement, maximum residual displacement postoperatively, quality of fracture reduction, incidence of complications, Majeed pelvic function score and classification at last follow-up were recorded and compared between the two groups.

Results

In the 5G group, 180 screws were implanted during surgery, while 213 screws were implanted in the control group. The 5G group demonstrated significantly reduced intraoperative blood loss and shorter incision length compared to the control group ( P<0.05). No significant difference was observed between the two groups in terms of operation time or hospital stay ( P>0.05). Radiographic evaluation revealed excellent and good reduction rates of 98.8% (79/80) in the 5G group and 97.5% (78/80) in the control group, while excellent and good screw placement accuracy rates were 98.3% (177/180) in the 5G group and 95.8% (204/213) in the control group. No significant difference was found between the two groups in maximum residual displacement, reduction quality, or screw placement accuracy ( P>0.05). All patients were followed up 7-16 months (mean, 11.3 months), with no significant difference in follow-up duration between the groups ( P>0.05). No perioperative or follow-up complication, such as wound infection, iatrogenic fractures, iatrogenic neurovascular injury, screw loosening or breakage, or nonunion, were observed in either group. The control group exhibited a worse degree of gait alteration compared to the 5G group ( P<0.05), while no significant difference was found in incidences of squatting limitation or persistent pain ( P>0.05). At last follow-up, no significant difference was observed between the groups in Majeed pelvic function scores or grading ( P>0.05).

Conclusion

Compared with the local surgery group, 5G remote robotic surgery supported by remote expert technical guidance demonstrated smaller incision lengths, less intraoperative blood loss, and fewer postoperative complications, and was shown to be a precise, minimally invasive, safe, and reliable surgical method.

The transhiatal tunnel valvuloplasty technique following laparoscopic proximal gastrectomy: the single-center experience in a retrospective cohort

BACKGROUND

The debate over the optimal reconstruction technique following proximal gastrectomy continues. Transhiatal tunnel valvuloplasty (ThTV) is a novel esophagogastrostomy method. This study aimed to evaluate the feasibility and safety of ThTV.

METHODS

A cohort with upper early gastric cancer or Siewert type II tumors who underwent laparoscopic proximal gastrectomy was retrospectively reviewed in a single center. The ThTV esophagogastrostomy procedure involved placing a lengthy gastric tube into the lower mediastinum and firmly binding it to the esophagus. Demographic and surgical morbidity data were extracted from the medical records.

RESULTS

Between March 2023 and November 2023, 15 patients underwent laparoscopic proximal gastrectomy using ThTV. The cohort consisted of 13 males and 2 females, with a median age of 68 years (range 49-77). The median operative time was 213 minutes (range 171-370). The median times for tunnel construction and anastomosis were 7 minutes (range 4-30) and 17 minutes (range 10-29), respectively. The median tumor size was 2.0 cm (range 1.0-5.0), and the median number of lymph nodes dissected was 29 (range 13-49). TNM staging revealed 9 cases of stage I, 5 cases of stage II, and 1 case of stage III. As of January 1, 2025, the median follow-up duration was 16.8 months (range 13.8-22.2). No tumor recurrence was observed. No patients reported severe reflux symptoms (Visick score ≥III). Gastroscopy confirmed reflux esophagitis (Los Angeles classification Grade A) in one patient, and an anastomotic stricture requiring endoscopic balloon dilation was observed in another patient.

CONCLUSIONS

Transhiatal tunnel valvuloplasty is a simple and reliable anti-reflux method following laparoscopic proximal gastric surgery. The further verification of the esophageal function is warranted.