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Upper Gastrointestinal (lips to ileocecal valve, including esophagus and stomach)

E442: Risk assessment for robotic to open gastrectomy conversion in gastric cancer patients

    ePoster Abstract Author(s)

  • Courtney Chen, MD (she/her/hers)

    Resident Physician
    Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
    Los Angeles, California, United States

    • Submitter(s)

  • Courtney Chen, MD (she/her/hers)

    Resident Physician
    Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
    Los Angeles, California, United States

    • Author(s)

  • Courtney Chen, MD (she/her/hers)

    Resident Physician
    Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
    Los Angeles, California, United States

  • TL

    Tiffany Lim, MD

    Resident Physician
    Department of Surgery, Cedars Sinai Medical Center, Los Angeles CA, United States

  • Annie Yang, MBBS (she/her/hers)

    Research Associate
    Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
    Duarte, California, United States

  • IL

    Ian Lau, n/a

    Undergraduate Research Assistant
    Brown University, United States

  • SD

    Supriya Deshpande, PhD

    Staff Scientist
    Department of Surgery, City of Hope National Medical Center, Duarte, CA, United States

  • Kelly M. Mahuron, MD

    Complex General Surgical Oncology Fellow
    Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
    Duarte, California, United States

  • BK

    Bradford Kim, MD

    Assistant Clinical Professor
    Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, United States

  • Laleh Melstrom, MD

    Associate Professor
    Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA
    La Verne, California, United States

  • IP

    Isaac B. Paz, MD

    Clinical Professor
    Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, United States

  • Yumon Fong, MD

    Professor
    Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
    Duarte, CA, California, United States

  • Yanghee Woo, MD

    Associate Professor
    Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
    Duarte, California, United States

Introduction: Robotic surgery for complex abdominal cancers including gastric cancer (GC) is increasing. Studies support the feasibility, safety, and comparable efficacy of robotic gastrectomy (RG) particularly for early cancers. However, factors influencing open conversion (OC) for RG and its safety following neoadjuvant chemotherapy (NAC) are not well understood.

Methods: A single institution retrospective review of a prospective database of GC patients who received radical resection at a high-volume comprehensive U.S. cancer center (Jan 2010– Oct 2022) was done.  RG standardization began in July 2015 with evolving patient selection criteria. To refine RG selection criteria, this study aimed to determine factors for OC and associated outcomes using univariate and multivariate logistic regression analyses.

Results: Of 289 gastrectomy cases, 133 (46.0%) were fully robotic. Prior to RG standardization, the OC rate was 24.8%, whereas afterwards the rate was 15% (n=20). 3 OC patients were pre-operatively identified as high risk for OC based on comorbidities and imaging. Variables for unplanned OC were hemodynamic instability upon insufflation (n=2, 10%), esophagojejunostomy difficulty (EJ) (n=3, 15%), bulky N2 station nodes (n=5, 25%), and tumor invasion/fibrosis (n=6, 30%). Factors associated with OC were hypertension (OR 1.17), current smoking (OR 1.41), other cancers (OR 1.42), prior abdominal surgeries (OR 1.46), combined resections (OR 1.94), COPD (OR 2.32), and cStages IIIC or IV (OR 2.48) (p< 0.05 all) while preoperative EUS decreased OC likelihood (OR 0.80, p< 0.05). Independent factors predictive of OC included COPD (OR 2.06, p=0.02), combined resection (OR 1.53, p< 0.01), and current smoking (OR 1.32, p=0.04); whereas early GC (OR 0.72, p=0.02) decreased risk. While mid (OR 0.72) and distal third (OR 0.76) tumors were less associated with conversion (p< 0.01 both) compared to proximal third tumors, tumor location was not an independent predictor (OR 0.96, p=0.46). Clinicopathologic factors of 121 NAC patients (41.9% overall; 37.8% non-robotic, 44.0% robotic, 73.7% converted) significantly differed from no-NAC patients with longer OP, LOS time (p< 0.05), but NAC did not significantly increase OC rates nor operative complications. However, NAC was associated with increased D2 lymphadenectomy completion (p< 0.01, OR 1.35). 

Conclusions: Key risk factors predictive of RG OC are preoperatively identifiable and can guide RG patient selection.  However, intraoperative findings such as intolerance to insufflation, difficult EJ and extensive tumor invasion or fibrosis continue to challenge RG for GC.   

Learning Objectives:

  • Upon completion, participant will be able to identify potential pre-operative risk factors that may increase the risk of conversion for robotic gastrectomy in gastric cancer patients
  • Upon completion, participant will be able to describe general intra-operative findings make it difficult to successfully complete a total robotic gastrectomy for gastric cancer patients
  • Upon completion, participant will be able to posit potential evidence that neoadjuvant chemotherapy does not negatively impact robotic gastrectomy outcomes in gastric cancer