www.clinicalrobotics.com Videopresentaiton Houston 2011 Clinical Robotic Surgery Association

1. Robotic Gastrectomy for Gastric Cancer: a European Experience A. Coratti, MD Chief, Department of Surgery Misericordia Hospital of Grosseto – Tuscany, Italy

2. Minimally invasive gastrectomy Historical steps Distal and total robotic gastrectomy 2001-2 Giulianotti Laparoscopic-assisted distal and total gastrectomy for advanced gastric cancer 1999 Azagra Hand-assisted laparoscopic distal gastrectomy 1999 Ohki Laparoscopic D2 gastrectomy 1999 Uyama Laparoscopic-assisted subtotal radical gastrectomy 1996 Choi Laparoscopic Billroth II gastrectomy 1995 Watson Laparoscopic-assisted Billroth I gastrectomy 1994 Kitano

3. Laparoscopic Gastrectomy Feasibility and safety Background CONCLUSIONS. Laparoscopic gastrectomy is a safe technical alternative to open gastrectomy for EGC with a lower overall complications and enhanced postoperative recovery. Open vs. Lap Gastrectomy for EGC Surg Oncol 2009 Yakoub D - 12 Studies, including 3 RCT and 951 pts. World J Gastroenterol 2006 Hosono S - 16 Studies, including 4 RCT and 1611 pts.

4. Robotic Gastrectomy Feasibility and safety Song J (Ann Surg 2009) Robot-assisted gastrectomy with lymph nodes dissection for gastric cancer (prospective analysis of100 cases) . CONCLUSIONS. Robotic assisted gastrectomy with lymphadenectomy can be applied safely and effectively for patients with gastric cancer. Bowel infarction 1% Mortality 36.7 (11-83) Retrieved lymph nodes 9 wound problems, 2 intraluminal bleedign, 2 anastomotic leakage 13% Morbidity Margins Blood loss Op. time Conversions Type of operation R0 in all cases 128ml (12-1400) 231min (155-330) None Lymphadenectomy: D2 / D1+ β 33 67 Gastrectomy total Gastrectomy subtotal

5. Robot-assisted Gastric Surgery Grosseto Experience Total series 2000-2011 Prof. Giulianotti (November 2000 – April 2007) Dr. Coratti (May 2007 – October 2011) 33 81 114 Robot-assisted gastrectomies

6. Mean age 67,3 yrs (range 39 – 93) Localization ASA Upper third 8 (8.2%) Middle third 28 (28.6%) Lower third 62 (63.2%) 44 Males 54 Females Age Gender Gastric adenocarcinoma: 98 pts. Robotic Gastrectomy for Carcinoma Grosseto Experience - IV 16 III 59 II 23 I

8. Robotic Gastrectomy for Carcinoma Grosseto Experience Postoperative outcomes - 2 All patients dead were ASA 3 4.1% (4/98) Mortality Anastomotic oesophageal leakage: - clinical 2/39 (5.1%) - radiological 5/39 (12.8%) Anastomotic gastro-jejunal leakage: - clinical 1/59 (1.7%), - radiological 2/59 (3.4%) Duodenal stump leakage 3/97 (3.1%) Other surgical complications 4/98 (4.1%) Medical complications 2/98 (2.04%) 19.3% (19/98) Morbidity Anastomotic leakage 3, bleeding 1, colonic infarction 1, stenosis of gastro-jejunal anastomosis 1 6.1% (6/98) Redo-surg Mean hosp stay Range: 4-30 days 8.7 days

13. TNM Staging 98 Gastric Carcinomas Robotic Gastrectomy for Carcinoma Grosseto Experience 1.1 10.2 5.1 11.2 25.5 17.3 29.6 % 27.6% 72.4% 1 IV IV 10 IIIC 5 IIIB 11 IIIA III 25 II II 17 IB 29 IA I N. pts. STAGE

14. Oncological adequacy Lymphadenectomy Correct staging of N parameter in 90.8% of cases Positive in 6 pts. (5 R1, 1 R2) 30.5 (9-80) Robotic Gastrectomy for Carcinoma Grosseto Experience

15. Resection margins 27.6% advanced tumors in our series (26/98 carcinomas were stage III-IV) Oncological adequacy 30.5 (9-80) Positive in 6 pts. (5 R1, 1 R2) 6.1% Robotic Gastrectomy for Carcinoma Grosseto Experience

16. Long term results Total series Robotic Gastrectomy for Carcinoma Grosseto Experience Mean 46.9 months (SD ±34.9) Median 38 months Range 3-116 months Time of follow-up 77 (78.6%) Pts. IN follow-up 17 (17.3%) Pts. OUT follow-up (missed) 4 (4.1%) Postop mortality 98 (100%) Total pts. (gastric carcinoma)

17. Robotic Gastrectomy for Carcinoma Grosseto Experience Long term results Follow-up on 77 patients 53.2% (41 pts.) Postop CHT 22.1% (17 pts.) Related cancer mortality 5.2% (4 pts.) Other mortality 11.4 months (range 3-48) Mean time of recurrence Distant mts: 23.4% (18 pts.) Local: 16.9% (13 pts.) NO port site mts Site of recurrence 24.5% (19 pts.) Stages I-II: 6 pts. (31.6%) Stages III-IV: 13 pts. (68.4%) Recurrence rate

18. Cancer Specific Survival Grosseto Experience Overall Survival ALL STAGES Cumulative OS at 5 years: 73.3% (95% CI 62.2-84.4) Median OS 38 months Mean OS 46.9 months (SD ± 34.9) Product-Limit Survival Analysis Cumulative Standard Lower Upper Event Survival Error 95% C.L. 95% C.L. At Total Time (T) S(T) of S(T) for S(T) for S(T) Risk Count Events 12,0+ 63 1 7 13,0 0,8864 0,0379 0,8122 0,9606 62 1 8 22,0 0,7933 0,0495 0,6963 0,8902 50 1 14 34,0 0,7550 0,0540 0,6492 0,8608 40 1 16 54,0 0,7334 0,0566 0,6226 0,8443 35 1 17 OS – All Stages Months

19. Overall survival STAGE IA Cumulative survival at 5 years: 100% (95% CI 100.0-100.0) Median OS 47 months Mean OS 56.8 months (SD ± 37.3) Product-Limit Survival Analysis Cumulative Standard Lower Upper Event Survival Error 95% C.L. 95% C.L. At Total Time (T) S(T) of S(T) for S(T) for S(T) Risk Count Events 16,0+ 21 1 0 23,0+ 18 1 0 47,0+ 12 1 0 56,0+ 11 1 0 72,0+ 10 2 0 115,0+ 2 2 0 OS – Stage IA Months Cancer Specific Survival Grosseto Experience

20. Overall survival Product-Limit Survival Analysis Cumulative Standard Lower Upper Event Survival Error 95% C.L. 95% C.L. At Total Time (T) S(T) of S(T) for S(T) for S(T) Risk Count Events 12,0 0,8462 0,1001 0,6500 1,0000 13 2 2 54,0+ 10 1 2 73,0+ 6 1 2 90,0+ 4 2 2 111,0+ 2 1 2 115,0+ 1 1 2 OS – Stage IB Months STAGE IB Cumulative survival at 5 years: 84.6% (95% CI 65.0-100.0) Median OS 69 months Mean OS 64 months (SD ± 34.5) Cancer Specific Survival Grosseto Experience

21. Overall survival Product-Limit Survival Analysis Cumulative Standard Lower Upper Event Survival Error 95% C.L. 95% C.L. At Total Time (T) S(T) of S(T) for S(T) for S(T) Risk Count Events 10,0 0,9444 0,0540 0,8386 1,0000 18 1 1 12,0 0,8889 0,0741 0,7437 1,0000 17 1 2 20,0 0,8333 0,0878 0,6612 1,0000 16 1 3 30,0 0,7692 0,1018 0,5697 0,9688 13 1 4 116,0+ 1 1 4 OS – Stage II Months STAGE II Cumulative survival at 5 years: 76.9% (95% CI 56.9-96.8) Median OS 54 months Mean OS 47.9 months (SD ± 37.9) Cancer Specific Survival Grosseto Experience

22. Overall survival Product-Limit Survival Analysis Cumulative Standard Lower Upper Event Survival Error 95% C.L. 95% C.L. At Total Time (T) S(T) of S(T) for S(T) for S(T) Risk Count Events 6,0 0,9412 0,0571 0,8293 1,0000 17 1 1 12,0 0,8824 0,0781 0,7292 1,0000 16 1 2 15,0 0,7563 0,1063 0,5480 0,9646 13 1 4 34,0 0,3223 0,1394 0,0490 0,5956 4 1 9 54,0 0,2149 0,1278 0,0000 0,4654 3 1 10 OS – Stage III Months STAGE III Cumulative survival at 5 years: 21.5% (95% CI 12.7-46.5) Median OS 16 months Mean OS 24.2 months (SD ± 22 .2) Cancer Specific Survival Grosseto Experience

23. Robotic gastrectomy OR and port setup

24. Robotic gastrectomy Robotic D2 lymphadenectomy video