Curative para-Aortic lymph node dissection Via INfra-mesocolonic approach in laparoscopic Gastrectomy (CAVING approach)

Efficiency of conversion surgery for esophageal squamous cell carcinoma with solitary abdominal para-aortic lymph node metastasis

PURPOSE

Abdominal para-aortic lymph nodes (PANs) are sites of distant metastasis in esophageal squamous cell cancer (ESCC). The prognosis of patients with Stage IVB ESCC and abdominal PAN metastasis is extremely poor. However, chemotherapy for ESCC has recently been developed, and the effectiveness of combined induction therapy and conversion surgery remains unclear. The primary objective of this study was to evaluate the short- and long-term outcomes of conversion surgery for ESCC and solitary abdominal PAN metastases after induction therapy.

METHODS

Thirteen patients who underwent conversion esophagectomy for cStage IVB ESCC with solitary abdominal PAN metastasis after induction therapy between January 2017 and October 2022 at our institution were enrolled. The short- and long-term outcomes of conversion surgery were retrospectively evaluated.

RESULTS

Three patients (23.1%) had pathological abdominal PAN metastasis, and six patients (46.2%) without pathological abdominal PAN metastasis showed that chemotherapy eliminated the tumors in the abdominal PAN. Three patients (23.1%) had postoperative complications of Clavien-Dindo grade II or higher. The 3-year overall and recurrence-free survival rates were 83.1% and 51.3%, respectively.

CONCLUSIONS

Our findings showed that conversion surgery for ESCC and solitary abdominal PAN metastasis led to a good prognosis when induction therapy was successful.

Robotic curative para-aortic lymph node dissection via INfra-mesocolon for gastric cancer: Robotic CAVING approach

BACKGROUND

Two major surgical complications in D2 plus para-aortic nodal dissection (PAND) for gastric cancer (GC) have been pancreatic fistula and abdominal abscess [1]. The increase in these complications is due to the excessive mobilization of the pancreas. We previously reported a laparoscopic Curative PAND Via INfra-mesocolon for GC (CAVING), which minimizes mobilization of the pancreas [2]. Robotic surgery may be more comfortable than laparoscopic surgery for the surgeon performing this CAVING approach because robotic surgery has ergonomic benefits and advantages, such as native wrist-like motion and three-dimensional vision. We initially report successful robotic CAVING approach on a 72-year-old male with GC with para-aortic nodal metastases (clinical stage IV) [3].

METHODS

We apply PAND after chemotherapy to patients with resectable gastric cancer who are suspected of having metastases to the lymph nodes around the para-aorta. CAVING approach minimizes mobilization of the pancreas and maximizes the view from the caudal side, which has been likened to cave exploration, a specialty of robotic surgery. The caudal side of the root of the superior mesenteric artery (SMA) can be dissected via the infra-pancreas, and only the cranial side of the SMA root requires a suprapancreatic approach.

RESULTS

After neoadjuvant chemotherapy using trastuzumab plus S-1 and oxaliplatin, robotic subtotal gastrectomy plus D2 with PAND was performed. The operation took 491 min (105 min for PAND) with no intraoperative complications, and blood loss of 92 ml. Final pathological examination showed complete response, yp stage 0 [3]. The patient was discharged uneventfully on postoperative day 17.

CONCLUSIONS

Robotic CAVING approach is feasible and safe in advanced GC with para-aortic nodal metastases, but its oncological value has yet to be determined.