Perioperative management - Gastrectomy, subtotal, robotically assisted

Primary Gastric Carcinoma

• In the case of a curative treatment approach and local resectability, surgery is generally indicated unless there are significant risk factors (pre-existing conditions or the patient's general condition, see contraindications).
• For locally advanced tumors in stages II and III (cT1/cT2N+ and cT3/resectable cT4Nx), pre-/perioperative chemotherapy should be administered.
• To achieve tumor-free resection margins (R0), except in mucosal carcinomas (T1a N0 M0), a proximal safety margin in the stomach of 5 cm (intestinal type according to Lauren) or 8 cm (diffuse type according to Lauren) in situ is usually required. The extent of resection (total versus subtotal gastrectomy) is determined by tumor location/spread and the safety margin required by the histological type.

Early Gastric Carcinoma

• An early gastric carcinoma is defined as a tumor confined to the mucosa and submucosa of the stomach wall, regardless of lymph node status, surface area, and distant metastasis. The muscularis propria of the stomach is, by definition, tumor-free.
• Differences in early carcinomas are seen in the frequency of potential lymph node metastasis. Tumors that have already infiltrated the submucosa are not suitable for endoscopic therapy, as there is a 4-20% probability of lymph node metastases.
• About 5% of patients show an early gastric carcinoma of the mucosal type (pT1m), where a curative treatment approach through endoscopic resection is possible, as the likelihood of lymph node metastasis is extremely low.
• Affected patients have an excellent prognosis with a five-year survival rate of > 90%.

Indications for Endoscopic Resection
Superficial gastric carcinomas confined to the mucosa (approximately 5% of patients) can be treated with endoscopic resection considering the following criteria:

• Lesions < 2 cm in size in elevated types
• Lesions up to 1 cm in size in flat types
• Histological differentiation grade: good or moderate (G1/G2)
• No macroscopic ulceration
• Invasion limited to the mucosa

Special Situations:

Gastric Stump Carcinoma (Recurrent tumors after subtotal gastrectomy):

• Completion gastrectomy resulting in total gastrectomy

Oligometastasis:

• As part of a multimodal approach within studies and the technical possibility of removing all metastatic sites.
• Metastases discovered intraoperatively can be resected analogously to the esophageal guideline if R0-resectable.

Peritoneal Metastases:

• Prerequisites:
  • o   PCI < 12
  • o   complete resection of all macroscopically visible tumor parts possible
• Procedure:
  • neoadjuvant systemic therapy
  • oncological resection (gastrectomy/subtotal gastric resection) with D2 lymphadenectomy and tumor-free resection margins
  • complete resection of peritoneal metastases (cytoreductive surgery)
  • hyperthermic intraperitoneal chemotherapy,

In palliative treatment approaches, gastrectomy may be indicated in rare cases (e.g., bleeding, perforation, stenosis).

Lymphadenectomy

• Lymph node dissection of compartments I and II is referred to as D2-LAD and represents the standard lymphadenectomy for gastric carcinoma. It can be considered the gold standard.
• Based on the Japanese classification (numbering), lymph nodes are grouped into several compartments. The D1 lymph nodes include stations 1 to 6, the D2 compartment additionally includes stations 7 to 11.
• The lymph nodes of station 12 are included in the oncological resection for distally located carcinomas on the lesser curvature. The lymph nodes at the main bile duct (station 12b, considered M1) are often not dissected to avoid injury/devitalization of the duct.
• The D3 compartment includes groups 12 to 15 and are not considered regional lymph node stations of the stomach by definition. As they are prognostically considered distant metastases, they are classified as M1 LYM if involved.
• To achieve a pN0 classification, the UICC requires a minimum of 16 regional lymph nodes to be examined. The German S3 guideline aims for a lymph node count of ≥ 25.

Patient-specific:

• Severely reduced general condition (e.g., due to tumor cachexia)
• ECOG status ≥ 2
• Relevant comorbidities with inability to undergo surgery or anesthesia, e.g.
• Liver cirrhosis Child B and C
• Poor cardiac and pulmonary function (NYHA status and GOLD status)
• High-grade carotid stenoses before therapy
• Adhesive abdomen concerning a minimally invasive approach

Tumor-related unresectability:

• Unresectable tumor with proximal infiltration of the superior mesenteric artery or the celiac trunk
• Any form of metastasis, unless the metastasis can be completely addressed as an R0 resection (e.g., locally limited peritoneal carcinomatosis, solitary liver metastasis, solitary distant lymph node metastasis).
• Complete portal vein thrombosis or other conditions with pronounced venous collateral circulation (liver cirrhosis).
• In case of passage obstruction or endoscopically uncontrollable tumor bleeding, gastrectomy may be indicated as a palliative procedure.

Contraindication for a subtotal gastrectomy:

• If, according to oncological surgical criteria, due to the location of the tumor and the histological type/spread pattern, the required safety margins (5 cm for the intestinal type and 8 cm for the diffuse type) cannot be maintained orally, a subtotal gastrectomy is contraindicated, and a total gastrectomy/possibly transhiatal extended gastrectomy is indicated.

mandatory:

• Blood chemical laboratory tests with so-called tumor markers (CA 72-4, CA 19-9, CEA)
• Esophagogastroduodenoscopy with step biopsies (at least 8 biopsies)
• Abdominal ultrasound: first imaging procedure to assess liver metastases.
• Endosonography to assess the T-stage, particularly to evaluate an early gastric carcinoma (mucosal/submucosal type). Identification of risk constellations uT3/4 N+ or detection of perigastric ascites. The assessment of lymph nodes in category N1 – 2 is possible, albeit with limited sensitivity and specificity.
• Abdominal/pelvic CT (with i.v. contrast): local situation, lymph nodes, liver metastases
• Thoracic CT to exclude pulmonary metastases
• MRI: Patients for whom a CT cannot be performed.
• PET-CT is not routinely recommended for the staging of gastric carcinomas.

Additionally for T3/T4

• Staging laparoscopy:
  • for suspected peritoneal metastasis: Since peritoneal metastasis cannot yet be reliably excluded by imaging procedures, diagnostic laparoscopy is generally recommended for patients with locally advanced gastric carcinoma (T3–T4) before starting neoadjuvant chemotherapy.
  • In up to 40% of cases, peritoneal metastasis is detected.
  • In addition to the possibility of histological confirmation of peritoneal metastases, diagnostic laparoscopy helps minimize unnecessary open exploratory attempts.
  • It can also detect previously unknown small subcapsular liver metastases, possibly with IOUS (intraoperative ultrasound) and biopsy.
  • A peritoneal lavage with cytology can be performed additionally. The likelihood of metachronous peritoneal metastasis is about 80% with the presence of positive lavage cytology. Studies are underway to identify patients who, despite a macroscopically negative finding, may benefit from additional therapeutic measures (HIPEC).
  • To enable complete parietal peritonectomy in the event of peritoneal metastasis, trocars should always be placed in the linea alba during diagnostic laparoscopy. Typically, two trocars are sufficient, a 10mm trocar for optics and a 5mm trocar for the biopsy forceps. Any trocar metastases that occur later can be easily removed during a median laparotomy.

• The neoadjuvant chemotherapy is an integral part of the treatment concept for gastric carcinoma.
• In the diagnosis of gastric carcinomas of stages II and III (cT1/cT2N+ and cT3/resectable cT4Nx), a perioperative chemotherapy "should" be performed according to the current guideline. This is typically started preoperatively (neoadjuvant) and continued postoperatively (adjuvant). This can increase the R0 resection rate, reduce the systemic recurrence rate, and improve the overall prognosis.
• As a perioperative concept, the FLOT regimen (5 Fluorouracil, Leucovorin, Oxaliplatin, Docetaxel) has become established in Germany and increasingly internationally. However, its prognostic value (over-treatment or meaningful concept) remains debated. (Gockel I, Lordick F. Neoadjuvant chemotherapy in gastric carcinoma. Chirurg. 2020 May;91(5):384-390.)
• After completion of the neoadjuvant therapy, it is recommended to evaluate the response using CT and endoscopy.

In planned preoperative chemotherapy:

1. Port implantation

2. Laparoscopic exploration for suspected peritoneal carcinomatosis

3. Possibly stent placement in case of dysphagia

In planned resection

• Preoperative nutrition: Possibly initiating a preoperative nutritional therapy in patients who have significantly lost weight preoperatively. A nutritional concept should be developed early, preferably at the beginning of multimodal therapy. Additionally, patients without signs of malnutrition should be motivated to take balanced oral nutritional supplements for 5–7 days preoperatively in addition to normal nutrition.
• The day before the operation day
  • Current blood chemistry laboratory tests, determine blood type, and order erythrocyte concentrates.
  • Thrombosis prophylaxis (LMWH (Low Molecular Weight Heparin), anti-thrombosis stockings) (see guideline for thrombosis prophylaxis in section 1.10).

General Surgical Risks:

• Thrombosis, pulmonary embolism
• Wound healing disorder
• Injury to internal organs (intestine, liver, spleen)
• Subsequent interventions
• Bleeding/rebleeding
• Pneumonia
• Urinary tract infection
• Heparin intolerance, HIT

Specific Surgical Risks:

• Conversion to an open procedure
• Mortality between 2 and 10%
• Final decision on the resection procedure only intraoperatively
• Anastomotic insufficiency
• Duodenal stump insufficiency
• Endoluminal/intra-abdominal bleeding
• Reduced blood flow to the gastric substitute
• Intra-abdominal abscess, peritonitis
• Pancreatitis or pancreatic fistulas
• Wound healing disorder
• Incisional hernia

Possibly Required Extension of the Procedure:

• Cholecystectomy
• Resection of liver metastases
• Splenectomy

Indications of:

• Temporary weight loss
• Changed eating habits
• Drains, gastric tube, urinary diversion
• Possibly blood transfusion

• Intubation anesthesia
• Nasogastric tube
• CVC (Central Venous Catheter)
• Epidural catheter (Peridural catheter)
• Indwelling catheter (transurethral) or intraoperative SPC (suprapubic bladder catheterization)

• The patient is positioned in a supine position with a slight reverse Trendelenburg on the large vacuum cushion. The left arm can be positioned separately. The use of the cushion eliminates the need for any additional supports. Before docking, the patient is tilted to a 15-degree reverse Trendelenburg position.

Caution:

• Positioning is of particular importance due to the docking of the patient to the robot's manipulator. There is a risk of abdominal wall injury if the patient slips.

The surgical team usually consists of two surgeons, the console surgeon and the table assistant. The table assistant is seated to the left of the patient. The video tower is positioned on the right at torso height. Anesthesia is at the head of the patient, and the OR nurse is located to the left caudal of the table assistant.

Robotic Instruments:

• Cardiere or Tip-Up Grasper,
• (Maryland bipolar Forceps),
• fenestrated bipolar Forceps,
• Camera (30°),
• monopolar Scissors,
• Vessel Sealer,
• Linear Stapler SureForm 60 with blue cartridge

Trocars:

Robotic

• Three 8 mm Robotic Trocars
• One 12 mm Robotic Trocar

Laparoscopic

• One 12 mm Assistant Trocar

Basic Instruments:

• 11 Scalpel
• Dissection Scissors
• Langenbeck Retractor
• Suction System
• Needle Holder
• Suture Scissors
• Forceps
• Compresses
• Swabs
• Suture material for the abdominal wall fascia in the area of trocars from 10 mm Vicryl 0 with UCLX needle, for the extraction incision PDS 0 or PDS 2/0. Subcutis (3-0 braided, absorbable), Skin (3-0 monofilament, absorbable)
• If necessary, Veress Needle
• If necessary, Backhaus Clamps
• Plaster

Additional Instruments

• Circular Stapler EEA 25 mm or 29 mm
• Gas System for Pneumoperitoneum
• Laparoscopic Atraumatic Grasper
• Laparoscopic Swab on a Stick
• Laparoscopic Suction-Irrigation System
• Specimen Retrieval Bag
• Alexis Wound Protector Size S/M + Glove
• Clip Applier if not robotic, e.g., Hemoloc® Clips

Instrument Setting for "Two Left Hands"

• Port 1 (8mm): Cardiere or Tip-Up Grasper
• Port 2 (8 mm): bipolar Forceps
• Port 3 (12 mm): Camera
• Port 4 (8 mm): Scissors/Vessel Sealer

Note: The ports are numbered here from right to left from the patient's perspective.

Instrument Setting for "Two Right Hands"

• Port 1 (8mm): Cardiere or Tip-Up Grasper
• Port 2 (8 mm): Camera
• Port 3 (12 mm): Linear Stapler
• Port 4 (8 mm): bipolar Forceps

Note: In X, the operation starts in the arm configuration 4-1-2-3 and switches to two right hands for stapling, so the 3rd port from the right can be used for stapling.

Additionally:

• Assistant Trocar:
• Clip Applier,
• atraumatic Bowel Graspers,
• Suction with Irrigation,
• Swab on a Stick
• Circular Stapler via Alexis Wound Protector Size S/M + Glove

Principles:

• preoperative eutrophy and normovolemia with fluid intake up to 2 hours preoperatively
• contemporary anesthesia management and use of regional techniques
• the greatest possible avoidance of drains and invasive accesses
• the most minimally invasive blood-sparing surgical technique
• postoperative pain therapy with reduction of opioid requirement
• early mobilization
• early nutritional build-up as well as
• timely discharge planning using discharge management.

In Detail:

• Intensive care monitoring (at least 24 hours)
• Remove intra-abdominal target drains depending on the amount of drainage
• Optionally, on the 5th postoperative day, an X-ray gastrointestinal passage or an endoscopic check of the anastomosis conditions can be performed.
• If splenectomy is performed: Vaccination against Streptococcus pneumoniae, Haemophilus influenzae, and meningococci!
• Gastrectomy: lifelong parenteral substitution of vitamin B12; if fatty stools occur, administration of pancreatic enzymes (Creon) is indicated.
• Iron and vitamin substitution (vitamin B12, folic acid, vitamin D) in the later postoperative course (approximately from the 3rd postoperative month).
• After preoperative chemotherapy, the decision on postoperative chemotherapy should be made interdisciplinarily depending on the degree of regression, clinical response, tolerability, and general condition. According to current German guidelines, it is recommended not to continue chemotherapy postoperatively in case of progression.

Follow-up: Upper abdominal tumors generally have a rather poor prognosis. For a long time, there was no consensus on how follow-up should be conducted. With increasingly potent, multimodal therapy concepts, patients with limited metastasis may possibly receive a second chance of cure through follow-up. For the first time, the current guideline recommends structured follow-up. It includes clinical and endoscopic as well as imaging control. The intervals should be at least semi-annually in the first 2 years and then annually until the 5th year.

Discharge: from the 5th postoperative day

Thrombosis Prophylaxis: Early mobilization, ATS (anti-thrombosis stockings), LMWH (low molecular weight heparin).
Due to the major intervention, there is a high risk of thromboembolism. Note: Kidney function, HIT II (history, platelet control).
Follow the link to the current guideline Prophylaxis of venous thromboembolism (VTE).

Postoperative Analgesia:

Note: Various scales are available for quantifying postoperative pain, with which the patient can determine their own pain level several times a day, such as the NRS (numerical rating scale 0–10), the VAS (visual analog scale), or the VRS (verbal rating scale).

Caution: Aim for the greatest possible avoidance of opioids and NSAIDs (adverse effects on bowel motility and anastomosis healing)

• Epidural catheter by anesthesia pain service 3rd postoperative day ex
• Basic medication: Oral analgesia: 4x1g Novalgin/3x1g Paracetamol, also combinable, e.g., fixed Novalgin and as needed Paracetamol up to 3x/day
• Administration of Novalgin: 1g Novalgin in 100 ml NaCl solution over 10 minutes as IV, or 1g as a tablet orally or 30-40 drops Novalgin orally
• Administration of Paracetamol: 1g IV over 15 minutes every 8h, or 1g suppository every 8h rectally (Caution: note anastomosis height), or 1g as tablets orally

Caution: The basic medication should be tailored to the patient (age, allergies, kidney function).

• As-needed medication: If VAS >= 4 as needed Piritramide 7.5 mg as IV or SC, or 5 mg Oxigesic acute
• if pain persists post-op >= 4 administration of a sustained-release opioid (e.g., Targin 10/5 2x/day)

Note: If pain occurs only during mobilization, an as-needed medication should be given 20 minutes before mobilization.

Note: Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current guideline for the treatment of acute perioperative and post-traumatic pain and observe the WHO step scheme.

Mobilization: Physical rest until wound healing is complete.

Physiotherapy: Early mobilization, breathing exercises

Nutritional Build-up: From the 1st postoperative day, start with sips of tea. Nutritional build-up traditionally begins cautiously with soup after 3–4 days. The catheter jejunostomy can be started with tea at 30ml/h from the 2nd postoperative day, consisting of half tea and half enteral nutrition solution from the 3rd postoperative day, and increased in quantity. Solid food after gastrointestinal passage.

Bowel Regulation:
If bowel movement does not occur spontaneously after 3–4 days, a mild laxative can be used.

Incapacity for Work:
Incapacity for work generally covers 3-4 weeks and is extended accordingly with a rehabilitative measure

Discharge Letter: The discharge letter should contain information about: diagnosis, therapy, course, histology, comorbidities, current medication, continuation of VTE prophylaxis, postoperative nutrition

Rehabilitation Treatment (AHB): if required/desired: register through the social service