Impact of Non-curative Endoscopic Submucosal Dissection on Minimally Invasive Distal Gastrectomy and on Robotic Versus Laparoscopic Approaches in pT1 Gastric Cancer

BACKGROUND/AIM: robotic distal gastrectomy after ESD is limited. PATIENTS AND METHODS: We retrospectively reviewed 169 patients with pT1 gastric cancer who underwent MIDG at a single center between April 2018 and December 2024; 43 had undergone non-curative ESD. Propensity score-matching produced 33 matched pairs for the primary comparison between patients with and without prior ESD. Perioperative metrics and early oncological outcomes were assessed. Perioperative and short-term oncological outcomes were compared between laparoscopic (n=33) and robotic (n=10) MIDG groups within the post-ESD cohort. RESULTS: After matching, operative duration, estimated blood loss, postoperative complication rates, and length of hospital stay were similar for the ESD and non-ESD groups. The ESD group showed a modest reduction in lymph node yield, but all resections were R0 and there were no recurrences; overall and relapse-free survival were comparable. In the post-ESD subgroup, the robotic approach required a longer operative time, largely due to docking and intracorporeal reconstruction; blood loss, lymphadenectomy yield, morbidity, and hospital stay were comparable to the laparoscopic approach. No disease recurrence was observed after either surgical approach during the follow-up period. CONCLUSION: Prior non-curative ESD did not appear to compromise perioperative safety or early oncological outcomes after MIDG for pT1 gastric cancer. Robotic MIDG is feasible following ESD and provides perioperative and short-term oncological outcomes comparable to laparoscopy; however, the small sample size of the robotic subgroup limits definitive conclusions. Larger prospective studies are warranted to confirm our findings and to clarify the role of robotic platforms in individualized lymphadenectomy after ESD.