Background: Docking the scope and instruments through a multi-channel trocar has enabled reduced-port robotic distal gastrectomy (RRDG) for gastric cancer. To facilitate lymphadenectomy over the anatomical hindrances during RRDG, we recently introduced the Vessel Sealer Extend^® (VSE) (Intuitive Surgical, Sunnyvale, CA, USA), a bipolar vessel-sealing device (BVSD) with an articulating jaw. Methods: From May 2020 to August 2023, we performed RRDG to treat T1 gastric cancer. One endoscope arm and three instrument arms of the da Vinci^® Xi Surgical System (Intuitive Surgical) were used. During the lymphadenectomy, the endoscope and VSE (Intuitive Surgical) were docked through a multi-channel trocar established on a trans-umbilical incision. Two Cardiere forceps were docked through cannulas established on each flank. A trans-umbilical lymphadenectomy using an articulating BVSD (TULAB) was then performed. Results: A total of 42 patients underwent planned RRDG with the TULAB technique. The number of retrieved lymph nodes did not differ between the patients who underwent RRDG and those who underwent conventional laparoscopic distal gastrectomies (CLDG) (p = 0.362). There was no statistically significant difference in postoperative complications between the RRDG and CLDG group (p = 0.189). The mean time to first semi-fluid diet was shorter in the patients who underwent RRDG than CLDG (p = 0.030), and the incidence of postoperative ileus was lower in the RRDG group than the CLDG group (0% and 9.9%, respectively, p = 0.034). Conclusions: Despite use of fewer ports, RRDG with TULAB had similar outcomes to CLDG in terms of the incidence of postoperative morbidity and the number of harvested lymph nodes. Furthermore, by reducing the number of incisions, the incidence of the intra-abdominal adhesions can potentially be lowered when RRDG is used.

Class I obesity (body mass index [BMI]: 30-34.9 kg/m 2) constitutes a considerable portion of the global obesity burden; however, traditional guidelines for metabolic bariatric surgery (MBS) have historically excluded this population. Recent updates in clinical consensus have expanded surgical eligibility, particularly for patients with obesity-related comorbidities refractory to medical treatment. To synthesize evidence from clinical studies, international guidelines, and expert consensus to assess the efficacy, safety, and long-term outcomes of MBS in patients with class I obesity. A comprehensive literature review was conducted, incorporating major clinical trials, observational cohorts, and meta-analyses published between 2006 and 2024. Weight loss, metabolic outcomes, and major surgical complication rates were examined. Recent studies demonstrate that MBS in patients with class I obesity achieves a total weight loss of 15.8-33.7%, and excess weight loss up to 102.7%, with type 2 diabetes mellitus remission rates frequently exceeding 60%. Complication rates remain low and are comparable to those observed in cohorts with higher BMI. Indirect comparisons suggest that the metabolic benefits and safety profiles in class I obesity are comparable to those in patients with higher BMI. Updated guidelines from international bariatric societies support MBS in class I obesity. MBS is an effective and safe treatment for weight loss and remission of comorbidities in class I obesity. Supported by recent guidelines and expert consensus, it should be considered as a valid treatment option for appropriately selected patients, with the potential to reduce their long-term healthcare burden.

Background/Objectives: Fat-free mass (FFM) loss after metabolic and bariatric surgery (MBS) is associated with adverse long-term outcomes, including osteoporosis. Identifying biomarkers that predict excessive FFM loss can improve perioperative patient management and postoperative risk stratification. This study investigated whether preoperative amino acid metabolite (AAM) levels could predict excessive FFM loss after laparoscopic sleeve gastrectomy (LSG). Methods: Forty patients with morbid obesity who underwent LSG between 2019 and 2020 were retrospectively analyzed. Based on the FFM loss to body weight loss ratio (%FFML/BWL) at 3 months postoperatively, patients were categorized into excessive (>25%) and non-excessive (≤25%) FFM loss groups. Anthropometric measurements and serum sampling were performed preoperatively and at 3, 6, and 12 months postoperatively. AAM profiles were collected before surgery. Statistical analyses, including logistic regression and receiver operating characteristic curves, were performed. Results: Twenty-five patients showed excessive FFM loss 3 months after surgery. They had significantly lower preoperative tyrosine (Tyr) levels (p = 0.025). Logistic regression revealed that higher Tyr levels were significantly associated with lower odds of being male, suggesting a potential protective effect (odds ratio (OR) =0.019, p = 0.010). Tyr profiling demonstrated acceptable predictive performance (area under the curve =0.715, p = 0.025). Despite nonsignificant p-values, trends showed lower FFM and muscle mass and higher fat mass in the excessive FFM loss group throughout follow-up. Conclusions: Preoperative Tyr profiling may help identify patients at risk for excessive FFM loss. These findings support prioritizing metabolic health alongside total weight loss in the evaluation of MBS outcomes.

Background: Palliative surgery is often considered for advanced stages of gastric cancer to reduce symptoms and improve quality of life; however, it is associated with considerable risks of postoperative complications and mortality. The aim of this study is to analyze the differences in severe complication rates and mortality between palliative and curative gastric cancer surgeries using data from a nationwide survey conducted by the Korean Gastric Cancer Association. Materials and Methods: Data from 12,420 patients who underwent gastric cancer surgery in 2019 were analyzed. Surgical procedures were categorized as total gastrectomies (TGs), distal gastrectomies (DGs), or bypass operations. Patients were divided into curative gastrectomy (CG, n = 12,114) and palliative surgery (PS, n = 306) groups. Postoperative complications were classified using the Clavien–Dindo (C-D) classification. Severe complications were defined as C-D grade IIIa or higher. Results: Compared with the CG group, the PS group had significantly higher rates of severe complications (10.2% vs. 4.8%, p < 0.001) and mortality (1.6% vs. 0.2%, p = 0.001). Leakage (3.9% vs. 1.3%, p = 0.001) and pancreatic fistula (1% vs. 0.2%, p = 0.036) were significantly more common in the PS group. When compared by resection extent, the PS group had higher severe complication rates than the CG group for DGs (13% vs. 3.8%, p < 0.001) and a higher mortality rate for TGs (3.3% vs. 0.3%, p = 0.006). Conclusions: Palliative gastric cancer surgeries are associated with significantly higher rates of severe complications and mortality than are curative surgeries. These findings emphasize the need for careful patient selection and thorough preoperative counseling when considering palliative gastric cancer surgery.

Fallata EM, et al. Foregut Surg. 2026 Jul;6(2):45-53. https://doi.org/10.51666/fs.2026.6.e6