Robotic Vagus-Sparing Total Gastrectomy for CDH1 Gene Mutation Treatment

Summary

This article focuses on robotic vagus-sparing total gastrectomy. The techniques and pitfalls of vagus preservation, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy are discussed.

Abstract

Hereditary diffuse gastric cancer (HDGC) caused by the CDH1 gene mutation is an inherited cancer syndrome that increases the risk of diffuse gastric cancer and is nearly impossible to detect by screening gastroscopy. The recommended preventative treatment is a total gastrectomy. Robotic surgery facilitates the use of minimally invasive surgical (MIS) techniques for anastomoses and posterior vagus preservation to potentially reduce adverse functional outcomes. An asymptomatic 24 year old male with the CDH1 gene mutation proven by genetic testing and a family history of a brother having a total gastrectomy for HDGC was treated with this technique. This video case report demonstrates the techniques and pitfalls of robotic surgery in terms of the patient positioning and port placement, posterior vagus-preserving dissection, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy. While these techniques are demonstrated in the case of prophylactic gastrectomy, many of them can be applied to other benign and bariatric foregut and general surgery types.Robotic surgery can facilitate the foregut MIS technique, as described in this case of a vagus-sparing total gastrectomy.

Introduction

Hereditary diffuse gastric cancer (HDGC) is characterized by a genetic mutation in the E-cadherin (CDH1) tumor suppressor gene, which has an autosomal dominant pattern of inheritance¹. This inherited cancer syndrome increases the risk of diffuse gastric cancer and lobular breast cancer (LBC). Current guidelines recommend testing for CDH1 mutations in patients with familial clusters of HDGC and LBC, particularly in those with early onset (before 40 years of age)². According to the largest reported series of CDH1 mutation carriers, the cumulative lifetime incidence of gastric cancer is 70% (95% CI, 59%-80%) for males and 56% (95% CI, 44%-69%) for females with this mutation³. However, recent studies have estimated gastric cancer penetrance with this mutation to be in the range of 37%-42% for males and 25%-33% for females¹.

Endoscopic surveillance with biopsies is the recommended surveillance type for those choosing to delay prophylactic gastrectomy; however, it is nearly impossible to detect early gastric cancer in this cohort using screening gastroscopy². Extensive white-light endoscopic examination is followed by a minimum of 30 non-targeted gastric biopsies from five separate areas of the stomach. However, this surveillance method has a high false-negative rate and only detects 20%-63% of occult signet ring cell foci^4,5.

Prophylactic total gastrectomy (PTG) is the recommended preventative treatment for any pathogenic or likely pathogenic CDH1 variant carrier starting at the age of 20 years, but it is not recommended beyond 70 years of age^1,2. Perigastric lymph node metastasis is an uncommon finding in asymptomatic patients, who typically have T1a or in situ signet ring cells. Perioperative morbidity is generally low, and patient satisfaction is high⁶. Though the overall quality of life following surgery is high, a truncal vagotomy is generally performed in a total gastrectomy^7,8. The resection of the vagus nerve above the level of the celiac and hepatic branches leads to parasympathetic denervation of the hepatobiliary tree and the small and large intestine. Post-vagotomy diarrhea and dumping syndrome are well-recognized long-term complications following PTG⁸.

Robotic surgery provides the surgeon with a 3-dimensional, 10x magnified view of the surgical field and offers a high degree of freedom with articulating surgical instruments⁹. The aim of preforming this technique is to potentially reduce adverse functional outcomes through posterior vagus preservation, which is facilitated by minimally invasive surgical (MIS) techniques.

Protocol

The patient provided informed consent for the publication of de-identified information, images, and video documentation. Associate Professor Dr. Michael Talbot (co-author) is an upper gastrointestinal surgeon accredited to perform gastrectomy at his institution. Due to the negligible risk of this case report and protocol, it was exempt from an ethics review as per the local institutional review board guidelines. Ethics application for case reports are exempted as per the local institutional review board guidelines. <…

Representative Results

The total operative time was 2 h 50 min, and the patient had an unremarkable postoperative course. The patient was placed on a free fluids diet on day 1 post surgery and discharged from the hospital on day 4. At the 1 month and 3-month follow-up, the patient was well and reported no diarrhea or dumping symptoms. The specimen was sent for pathological examination and demonstrated five areas of superficial invasion of the lamina propria by signet ring cell adenocarcinoma. These areas were micros…

Discussion

An asymptomatic 24 year old male with the CDH1 gene mutation proven by genetic testing and a family history of a brother having a total gastrectomy for HDGC was selected. The preoperative endoscopy was unremarkable. The case is used as a platform to discuss the techniques and the pitfalls of key aspects of it. This includes the patient positioning and port placement, posterior vagus-preserving dissection, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a triple stapled jejunojejuno…

Materials

Laparoscopic instruments
5 mm optical entry port	Applied Medical	CFF03	Kii Fios First entry access system.
Laparoscopic 5mm 0° camera	Olympus	ENDOEYE HD II	5 mm, 0°
Laparoscopic needle holder	KARL STORZ		Laparoscopic needle holder
Nasogastric tube	Cardinal Health	8888264960E	16Fr
Nathanson liver retractor	COOK Medical	NLRS-1001/ NLRS-1002	Large/ Extra-large
Robotic instruments
12 mm port	Intuitive Surgical	470375
8 mm port	Intuitive Surgical	470380
8 mm reducer	Intuitive Surgical	470381
Da Vinci Xi/X Endoscope with Camera, 8 mm, 0°	Intuitive Surgical	470026
Da Vinci Xi/X Endoscope with Camera, 8 mm, 30°	Intuitive Surgical	470027
da Vinci Xi Surgical System (DVSS)	Intuitive Surgical	1	N/A
Force Bipolar 8 mm	Intuitive Surgical	470405
Mega SutureCut Needle Driver	Intuitive Surgical	470309
Monopolar hook diathermy	Intuitive Surgical	470183
SureForm 60mm stapler	Intuitive Surgical	480460
Tip-up fenetrated grasper 8 mm	Intuitive Surgical	470347
Vessel Sealer Extend 8 mm	Intuitive Surgical	480422
Stapler reloads
Seamguard buttress 60 mm	GORE	1BSGXI60GB/12BSGXI60GB
SureForm 60 mm green reload	Intuitive Surgical	48360G
SureForm 60 mm white reload	Intuitive Surgical	48360W
Sutures
2-0 nonabsorbable barbed suture	Medtronic	VLOCN0644	23 cm V-Loc on a 26 mm ½ circle taper point needle
3-0 absorbable barbed suture	Medtronic/ Ethicon (J&J)	VLOCM0644	23 cm V-Loc on a 26 mm ½ circle taper point needle (preferred), STRATAFIX (alternate). Catalogue number
2-0 monocryl suture	Ethicon (J&J)	JJW3463	Cut to 15 cm, taper point needle
2-0 silk suture	Ethicon (J&J)	JJ423H	Cut to 15 cm, taper point needle
1 PDS suture	Ethicon (J&J)	JJ75414	Fascial closure
3-0 monocryl suture	Ethicon (J&J)	JJY227H	Skin closure
Topical Skin Adhesive	Ethicon (J&J)	JJ79025	Skin closure/ wound dressing
Specimen extraction
Alexis O-ring wound retractor	Applied Medical	C8402	Medium. For specimen extraction
Handheld diathermy	Covidien/ Valleylab	VLE2515	For specimen extraction