Upper gastrointestinal tract and robotic visceral surgery

Every year, around 60 per 1000 inhabitants have to undergo abdominal surgery; in 2021, over 118,000 surgical procedures were performed on the digestive organs. Visceral surgery is also constantly evolving, and many recent studies focus on robotic-assisted surgery as well as prognosis improvement in tumor patients. We present an update on visceral surgery with special consideration of aspects relevant or interesting for gastroenterology.

Every year, around 60 per 1000 inhabitants have to undergo abdominal surgery; in 2021, over 118,000 surgical procedures were performed on the digestive organs [1]. Many patients are either diagnosed on an interdisciplinary basis or switch between gastroenterology and visceral surgery during treatment, so that the term visceral medicine is being coined more and more frequently. Visceral surgery is also constantly evolving, and many recent studies focus on robotic-assisted surgery as well as prognosis improvement in tumor patients. Here we present an update on visceral surgery with special consideration of aspects relevant or interesting for gastroenterology.

Since this is an extensive area, we have split the update into two parts. Part 1 deals with the upper gastrointestinal tract as well as innovations and developments in robotic visceral surgery. Another article in the next issue will discuss the lower gastrointestinal tract as well as parietology/abdominal wall surgery and perioperative medicine. The two articles build on the articles published in Hausarzt Praxis 1+2/2021 [2,3] in 2021.

Methodology

The literature from the years 2021 to 2023 was searched for thematic relevance. The search was conducted via Pubmed (www.pubmed.gov) and UpToDate (www.uptodate.com/contents/search) for the following subcategories: Upper gastrointestinal tract, bariatrics, hepatobiliary and pancreatic surgery and robotic visceral surgery.

Esophageal Cancer

Esophageal cancer is one of the most aggressive gastrointestinal cancers. For a long time, the standard operation was the open abdomino-thoracic esophagectomy according to Ivor Lewis. Due to the high postoperative morbidity and limited quality of life, minimally invasive procedures have come to the fore in recent years and have found their way into the guidelines. In the short term, better results were achieved with regard to pulmonary complications, wound infections and sepsis, with comparable oncological results, so that in some publications minimally invasive esophagectomy is already described as the standard [4,5].

Gastric Cancer

In recent years, laparoscopic surgery has been compared with open surgery in several studies in both Asia and Europe. With the same oncological results, the long-term complication rates are significantly lower, although the operation time is increased [6]. In early gastric carcinomas, which account for almost half of new diagnoses, especially in Asia, organ-preserving resection with sentinel lymph node extirpation was shown to be equivalent to “classic” laparoscopic gastrectomy with lymphadenectomy in terms of 3-year disease-specific survival and 3-year overall survival, although non-inferiority to standard therapy could not be demonstrated [7].

Reflux disease

Almost 20% of the population suffer from gastroesophageal reflux symptoms. Proton pump inhibitors (PPI) are the backbone of treatment. In PPI-refractory patients, fundoplication is still considered the gold standard of treatment, although the implantation of a mesh in addition to crurorrhaphy has been the subject of controversial debate for years. Long-term data from Sweden now show that the additional use of a non-absorbable mesh for hiatoplasty is associated with significantly higher dysphagia scores, with the same rate of recurrent hiatal hernias [8].

Esophageal magnetic band implantation (MSA) as an alternative to fundoplication is considered a promising treatment option. A more recent comparative study shows comparable quality of life data after MSA compared to Nissen or Toupet fundoplication, but shows methodological weaknesses [9]. There is still a lack of reliable long-term data from prospective studies.

Bariatric surgery

Obesity is increasing worldwide, in the USA more than 40% of adults are obese. Bariatric surgery is the most efficient treatment with a permanent excess weight loss of 51.9% after Roux-Y gastric bypass (RYGB) and 43.5% after sleeve gastrectomy, with a higher weight loss after RYGB and a higher incidence of gastroesophageal reflux after sleeve gastrectomy [10]. A highly significant reduction in overall mortality of 37% (HR: 0.63; 95% CI 0.60-0.66; p<0.001) can already be demonstrated after a follow-up of four years after bariatric surgery, which is primarily attributed to the reduced incidence of cardiovascular events [11]. Bariatric surgery also reduces the incidence of liver-associated complications by two thirds, although there is a slight increase in the risk of alcoholic liver cirrhosis [12]. A large cohort study with over 30,000 patients showed that bariatric surgery almost halves the risk of specific tumor diseases and also reduces mortality [13].

Pancreatic tumors

Minimally invasive surgical techniques are also becoming increasingly important in pancreatic surgery, with less blood loss and shorter hospital stays with the same 90-day mortality [14]. Neoadjuvant therapy is now well established, particularly for locally advanced pancreatic tumors, and current data is increasingly shedding light on which patients benefit from it. Patients after neoadjuvant radiochemotherapy show significantly better long-term survival compared to adjuvant therapy, although the chemotherapy regimen studied is considered outdated [15]. In patients after neoadjuvant therapy, it was shown that a CA 19-9 level of >100 U/ml was the best predictor of early recurrence after curative intent resection [16], whereas a decrease in CA 19-9 by ≥60% compared to baseline was associated with significantly improved overall survival [17].

Pancreatitis

Biliary obstruction is the most common cause of acute pancreatitis in Europe, followed by alcohol [18,19]. A Chinese working group investigated the effect of early abdominal paracentesis in severe pancreatitis, with a significant reduction in overall mortality (3.7% vs. 8.2%, p<0.05) and an equally significant reduction in disease-specific mortality and surgery rate [20]. In chronic pancreatitis, the trend towards early surgical intervention continues to increase. A recent review shows that pain control is better with the same rate of new-onset endocrine and exocrine pancreatic insufficiency and comparable length of stay [21].

Gall bladder and biliary tract disease

Cholecystectomy after biliary pancreatitis is recommended in the guidelines. In moderate and especially in severe acute pancreatitis, early cholecystectomy was associated with an increased risk of mortality and morbidity, with the “ideal” time of surgery being within the first eight weeks after discharge [22,23].

Hepatocellular carcinoma

Hepatocellular carcinoma is the most common primary liver tumor. In early stages, surgical resection is an option in addition to local ablative procedures. Laparoscopic and robotic liver resection in early stages (BCLC 0-A) are equivalent to open liver resection in terms of overall survival [24].

Liver metastases

15-25% of all patients with colorectal carcinomas have liver metastases at the time of diagnosis; in the meantime, it is recommended to remove these simultaneously with the primary tumor in the case of resectable findings. If simultaneous resection is not possible, the primary focus should be on the liver. In a large retrospective study with propensity-score matching from China, it was shown that the sequence during simultaneous surgery is irrelevant with regard to the feared infectious complications, with similar tumor-specific survival [25]. In a large European multicenter study, risk factors for R1 resection of colorectal liver metastases in open and laparoscopic liver surgery were evaluated: it was shown that the choice of procedure has no direct influence on R status, but the resection technique, number of lesions and their size do. In addition, the combination of atypical and anatomical liver resection was shown to be a risk factor for R1 resection [26].

Gastrointestinal complications of COVID-19.

The Covid-19 pandemic has posed major challenges for healthcare worldwide. As a result, it has been shown that COVID-positive patients with acute cholecystitis are significantly more likely to have necrotizing cholecystitis than Covid-negative patients and – unsurprisingly – show higher morbidity and mortality [27]. Another cohort showed that patients with acute cholecystitis during the corona pandemic were diagnosed significantly later and underwent surgery with greater delay after diagnosis, leading to longer hospital stays and higher morbidity rates [28]. In contrast, results show that a delay of less than eight weeks does not worsen surgical outcomes in patients with gastric cancer [29]. The results of large studies over the long term are still pending, although an important study from 2021 clearly shows that during the COVID-19 pandemic, one in seven patients was unable to undergo the recommended tumor surgery [30].

Robotics in visceral surgery

Robotic surgery has become firmly established in visceral surgery in recent years, both in oncological and non-oncological surgery. Due to the higher degrees of freedom of the robotic instruments compared to conventional laparoscopy, the use of a surgical robot is particularly advantageous in “narrow” anatomical areas such as the small pelvis, the upper GI tract and the thorax. In addition to the technical aspect, the results for patients are the most important argument for the increasing spread of robotic surgical techniques.

In one of the largest reviews on the subject, which was only recently published, it was shown for a series of oncological operations including prostatectomies, hysterectomies and lobectomies, but also rectal resections, that robotic surgery is at least not inferior to conventional laparoscopic (/thoracoscopic) or open techniques [31]. Particular attention is currently being paid to esophageal surgery: several studies have recently been published showing that robotic esophageal surgery has significantly fewer anastomotic failures and a significantly higher rate of complication-free postoperative outcomes compared to hybrid esophagectomy or conventional laparoscopic surgery [32]while compared to open surgery, the operation time was significantly longer and there were more pulmonary embolisms [33]. The largest meta-analysis to date comparing robotic esophagectomy (RAMIE) with conventional laparoscopic esophagectomy shows a significantly improved 3-year disease-free survival with a trend towards improved 3-year overall survival and a significantly reduced incidence of postoperative pulmonary complications. The improvement in disease-free survival is explained by the authors with the higher number of robotically resected lymph nodes. The other postoperative results are comparable between RAMIE and conventional laparoscopic esophagectomy [34]. In colon and especially rectal surgery, the data situation is somewhat less extensive. Nevertheless, here too robotics can probably be classified as equivalent to conventional laparoscopic procedures, at least with regard to long-term oncological results [35]. One of the largest prospective randomized studies in rectal surgery recently published short-term results. Over 1700 patients with tumors of the middle and deep rectum (<10 cm from the anocutaneous junction) who were randomized to either laparoscopic or robotic rectal resection were compared. The primary endpoint could not yet be evaluated at the time of publication in November 2022 (follow-up too short). In all secondary endpoints examined (rate of positive circumferential resection margins, Clavien-Dindo grade ≥2 complications, rate of macroscopically complete resections, re-establishment of bowel passage, length of hospital stay, rate of abdominoperineal rectal extirpations, rate of conversions to open surgery, intraoperative blood loss, intraoperative complication rates), there was a significant advantage in favor of the robotic group. The 3-year recurrence rate as a primary endpoint will probably be published in early 2024. The increased material costs of robotic surgery should not be neglected, and the learning curves for implementing the technique are also the subject of discussion, with learning curves of up to 80 cases, e.g. for esophageal resection [36]. This is offset by shorter hospitalization times, less blood loss and lower perioperative morbidity rates, which can easily compensate for the even higher material costs.

Take-Home Messages

• There is a trend towards center surgery in abdominal tumor surgery, although this is not synonymous with a better outcome.
• Bariatric surgery not only leads to the most stable long-term weight loss, but also reduces overall mortality.
• Neoadjuvant chemotherapy for pancreatic cancer leads to better long-term survival in borderline resectable and resectable pancreatic cancer.
• In chronic pancreatitis, early surgery offers significantly better pain control with the same risk profile as interventional treatment.
• Robotic visceral surgery is showing promising developments, particularly in surgery of the upper GI tract and esophagus, with lower complication rates compared to laparoscopic techniques.

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