Robot-assisted minimally invasive esophagectomy

Fully robotic side-to-side stapled anastomosis provides less anastomotic leakage than conventional minimally invasive approach in Ivor Lewis esophagectomy

INTRODUCTION

This study evaluates surgical outcomes of minimally invasive Ivor Lewis esophagectomy (ILE) for esophageal and esophagogastric cancer, with the comparison of the robotic approach (RA) and the conventional minimally invasive approach (CA).

METHODS

Selected patients who underwent minimally invasive ILE for esophageal cancer were included between January 2017 and December 2023. We retrospectively investigated the patients' background characteristics and the short-term surgical outcomes.

RESULTS

In this period, among a total of 840 esophagectomies, 81 patients (9.6%) underwent minimally invasive ILE, consisting of 24 cases with RA and 57 with CA. The major indications for ILE were adenocarcinoma of the distal esophagus or esophagogastric junction and patients with prior head and neck cancer treatment. Among these thoracic approaches, there were no significant differences in the patients' indications and characteristics, including age, histology, tumor location, clinical TNM stage, and preoperative therapy. Compared with the CA group, no anastomotic leakage was observed in the RA group (17.5% vs. 0, p = .035). Rates of total postoperative complications and length of hospital stay also tended to be reduced in the RA group but did not reach significance.

CONCLUSION

In the Ivor Lewis esophagectomy with a side-to-side linear-stapled anastomosis, the fully robotic approach has the potential to powerfully reduce anastomotic leakage compared to the conventional minimally invasive approach.

Unveiling Therapeutic Targets for Esophageal Cancer: A Comprehensive Review

Esophageal cancer is a highly aggressive and deadly disease, ranking as the sixth leading cause of cancer-related deaths worldwide. Despite advances in treatment, the prognosis remains poor. A multidisciplinary approach is crucial for achieving complete remission, with treatment options varying based on disease stage. Surgical intervention and endoscopic treatment are used for localized cancer, while systemic treatments like chemoradiotherapy and targeted drug therapy play a crucial role. Molecular markers such as HER2 and EGFR can be targeted with drugs like trastuzumab and cetuximab, and immunotherapy drugs like pembrolizumab and nivolumab show promise by targeting immune checkpoint proteins. Epigenetic modifications offer new avenues for targeted therapy. Treatment selection depends on factors like stage, tumor location, and patient health, with post-operative and rehabilitation care being essential. Early diagnosis, appropriate treatment, and supportive care are key to improving outcomes. Continued research is needed to develop effective targeted drugs with minimal side effects. This review serves as a valuable resource for clinicians and researchers dedicated to enhancing esophageal cancer treatment outcomes.

Robot Assisted Laparoscopy Combined with Thoracoscopy in the Treatment of Hepatocellular Carcinoma with Inferior Vena Cava Tumor Thrombus

BACKGROUND

Facing the 0.7-22% incidence rate of hepatocellular carcinoma (HCC) with inferior vena cava tumor thrombus (IVCTT), there are usually no obvious symptoms and signs when the tumor thrombus completely blocks the IVCTT in the early stage.1.J Gastroenterol. 29:41-46;2.Hepatogastroenterology. 41:154-157;3.Clin Cardiol. 19:211-213; Once diagnosed, it is the end-stage manifestation without unified treatment for HCC with IVCTT, bringing poor prognosis. Without active treatment, the median survival time is only 3 months. Previous scholars believed that patients with IVCTT should not adopt active surgical treatment. With the advance of technology, active surgical treatment has significantly lengthened the survival time with IVCTT.4.Ann Surg Oncol. 20:914-22;5.World J Surg Oncol. 11:259;6.Hepatogastroenterology. 58:1694-1699; However, for patients with HCC and IVCTT, open surgery was always selected in the past by opening the diaphragm through the combined thoracoabdominal incision to block the superior and subhepatic vena cava, leading long incision and huge trauma. With the development of minimally invasive techniques, laparoscopy thoracoscopy has showed great advantages in the treatment of HCC with IVCTT. A patient underwent laparoscopic with thoracoscopic resection of tumor and cancer thrombectomy after neoadjuvant therapy and then survived after follow-up.7.Ann Surg Oncol. 29:5548-5549 Therefore, it used as a first reported case of robot-assisted laparoscopic with thoracoscopic treatment of HCC complicated inferior vena cava cancer thrombectomy.

METHODS

A 41-year-old man had a liver space-occupying lesion discovered during his medical examination 2 months ago. The diagnosis of HCC with IVCTT was confirmed by enhanced CT and biopsy specimen in the first hospitalization. A combination of TACE, targeted therapy, and immunotherapy plan was applied for the patient after multidisciplinary treatment (MDT). Specifically, Lenvatinib was taken orally 8 mg daily and 160 mg of toripalimab was given intravenously every 3 weeks. His reexamination CT showed that the tumor was more advanced after 2 months of treatment. The surgical operation was performed based on comprehensive consideration. The patient was placed in the left lateral decubitus position, and a thoracoscopic prefabricated the inferior vena cava above diaphragm blocking device was pulled out of the incision. The patient was switched to a supine position with the head of the bed raised 30 degrees. The gallbladder was removed first after entering the abdominal cavity, then prefabricated first hilar blocking band. Sterile rubber glove edges and hemo-lock were used to fabricate the blocking device. The novel hepatic inflow occlusion device is a safe, reliable, and convenient technique that is associated with favorable perioperative outcomes and low risk of conversion.8.Surg Endosc. 34:2807-2813 The liver along the middle hepatic vein was cut to expose the anterior wall of the inferior vena cava, then prefabricated posterior inferior vena cava blocking belt and right hepatic vein blocking belt. Finally, the first portal of liver, right hepatic vein, retrohepatic inferior vena cava, and inferior vena cava above diaphragm were blocked in sequence, so that accomplishing tumor resection and thrombectomy of inferior vena cava. It should be emphasized that before the inferior vena cava is completely sutured, the retrohepatic inferior vena cava blocking device should be released to allow blood flow to flush the inferior vena cava. Moreover, transesophageal ultrasound is required to real-time monitor inferior vena cava blood flow and IVCTT. Some images of the operation are shown in Fig. 1. Fig. 1 (a) Layout of the trocar. ①Make a 3cm small incision between the right anterior axillary line and the midaxillary line, parallel to the fourth and fifth intercostal spaces; a puncture hole in the next intercostal space for endoscope; ②2cm above the intersection of umbilicus horizontal line and axillary front line; ③Intersection of right clavicular midline and umbilical horizontal line; ④Superior margin of umbilicus; ⑤The midpoint of '④ & ⑥'; ⑥2cm below the intersection of left clavicular midline and left costal margin. (b) Prefabricated the inferior vena cava blocking device above diaphragm by thoracoscopic. (c) The smooth tumor thrombus protruding into the inferior vena cava RESULTS: It took 475 min to finish the operation, and the loss of blood was estimated as 300 ml. The patient was discharged from hospital 8 days after the operation without postoperative complication. HCC was confirmed by postoperative pathology.

CONCLUSIONS

Robot surgical system reduces the limitations of laparoscopic surgery by offering a stable three-dimensional view, 10-times-enlarged image, restored eye-hand axis, and excellent dexterity with the endowristed instruments, which has several advantages over open operation such as diminished blood loss, reduced morbidity, and shorter hospital stay.9.Chirurg. 88:7-11;10.BMC Surg. 11:2;11.Minerva Chir. 64:135-146; Furthermore, it could favor the operative feasibility of difficult resections reducing the conversion rate and playing a role to extend the indications of liver resection to minimally invasive approaches. It may provide new curative options in patients deemed inoperable with conventional surgery, such as HCC with IVCTT.12.Biosci Trends. 16:178-188;13.J Hepatobiliary Pancreat Sci. 29:1108-1123.

[Robotic esophageal surgery]

Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly becoming established as a standard procedure in surgical centers for esophagectomy in cases of cancer. To date, RAMIE has been shown to have fewer postoperative complications and at least equivalent oncological outcomes compared with open resection. Compared with classical minimally invasive resection, there seem to be fewer cases of postoperative pneumonia after RAMIE. In addition, a higher number of harvested lymph nodes could lead to better oncological long-term outcomes. The learning curve for this complex surgical procedure is relatively shallow but can be greatly reduced at high-volume centers through special training and proctoring programs. Robotic surgical approaches have also been described for other esophageal diseases; however, no clear superiority compared to laparoscopic surgery has so far been shown.

Safety and Feasibility of Robot-Assisted Minimally Invasive Esophagectomy (RAMIE) with Three-Field Lymphadenectomy and Neoadjuvant Chemoradiotherapy in Patients with Resectable Esophageal Cancer and Cervical Lymph Node Metastasis

BACKGROUND

In the West, patients with cervical lymph node metastasis of resectable esophageal cancer at diagnosis are generally precluded from curative treatment. This study prospectively explored the safety and feasibility of neoadjuvant chemoradiotherapy followed by robot-assisted minimally invasive esophagectomy (RAMIE) with three-field lymphadenectomy for these patients.

METHODS

Between 2015 and 2021, patients with resectable thoracic esophageal cancer and cervical lymph node metastasis were recruited nationwide in the Netherlands. Patients without interval metastasis following neoadjuvant chemoradiotherapy and good physical condition underwent RAMIE with bilateral three-field lymphadenectomy. Safety was predefined as ≤50% Clavien-Dindo grade ≥3b postoperative complications.

RESULTS

Neoadjuvant chemoradiotherapy was administered to 29 patients (19 (66%) adenocarcinoma and 10 (34%) squamous cell carcinoma). After restaging, nine (31%) patients were excluded (interval metastasis, clinical deterioration, or withdrawn consent). RAMIE was performed in 20 patients (R0-rate 95%). A median of 42 [range 21-71] lymph nodes were resected of which 13 [range 2-35] were cervical. Only 1 (5%) patient had an unexpected contralateral cervical lymph node metastasis. Complications grade ≥3b occurred in 50%. Most frequent complications of any grade were recurrent laryngeal nerve palsy (45%) and pneumonia (40%). Overall survival at 1 year was 85% and quality of life at 6 months was comparable to esophageal cancer patients treated with curative intent.

CONCLUSIONS

RAMIE with three-field lymphadenectomy following neoadjuvant chemoradiotherapy for patients with resectable esophageal cancer presenting with cervical lymph node metastasis is feasible in a Western population. Because contralateral cervical metastasis is rare, a unilateral neck dissection would suffice in the majority of cases.

CLINICAL TRIAL

gov Identifier: NCT02426879. Dutch trial register Identifier: NTR 4552.

Network meta-analysis of randomized controlled trials on esophagectomies in esophageal cancer: The superiority of minimally invasive surgery

BACKGROUND

Previous meta-analyses, with many limitations, have described the beneficial nature of minimal invasive procedures.

AIM

To compare all modalities of esophagectomies to each other from the results of randomized controlled trials (RCTs) in a network meta-analysis (NMA).

METHODS

We conducted a systematic search of the MEDLINE, EMBASE, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and CENTRAL databases to identify RCTs according to the following population, intervention, control, outcome (commonly known as PICO): P: Patients with resectable esophageal cancer; I/C: Transthoracic, transhiatal, minimally invasive (thoracolaparoscopic), hybrid, and robot-assisted esophagectomy; O: Survival, total adverse events, adverse events in subgroups, length of hospital stay, and blood loss. We used the Bayesian approach and the random effects model. We presented the geometry of the network, results with probabilistic statements, estimated intervention effects and their 95% confidence interval (CI), and the surface under the cumulative ranking curve to rank the interventions.

RESULTS

We included 11 studies in our analysis. We found a significant difference in postoperative pulmonary infection, which favored the minimally invasive intervention compared to transthoracic surgery (risk ratio 0.49; 95%CI: 0.23 to 0.99). The operation time was significantly shorter for the transhiatal approach compared to transthoracic surgery (mean difference -85 min; 95%CI: -150 to -29), hybrid intervention (mean difference -98 min; 95%CI: -190 to -9.4), minimally invasive technique (mean difference -130 min; 95%CI: -210 to -50), and robot-assisted esophagectomy (mean difference -150 min; 95%CI: -240 to -53). Other comparisons did not yield significant differences.

CONCLUSION

Based on our results, the implication of minimally invasive esophagectomy should be favored.

Outcomes of Minimally Invasive and Robot-Assisted Esophagectomy for Esophageal Cancer

Simple Summary

This is an invited review for the special edition, “Minimally Invasive Surgery for Cancer: Indications and Outcomes.” Indications to perform minimally invasive techniques for esophagectomy rather than the classic open technique do not exist. This review outlines the current research by comparing outcomes among minimally invasive esophagectomy, robot-assisted esophagectomy, and open esophagectomy. After determining the benefits of each technique in terms of each outcome, the discussion focuses on how surgeons may use the presented information to determine which approach is most appropriate. We hope this study provides a comprehensive review of the current state of the literature regarding minimally invasive esophagectomy, as well as a guide for surgeons who treat patients with esophageal cancer.

Abstract

With the evolution of minimally invasive esophagectomy (MIE) and robot-assisted minimally invasive esophagectomy (RAMIE), questions remain regarding the benefits and indications of these methods. Given that set indications do not exist, this article aims first to review the reported outcomes of MIE, RAMIE, and open esophagectomy. Then, considerations based on the reported outcomes are discussed to guide surgeons in selecting the best approach. MIE and RAMIE offer the potential to improve outcomes for esophagectomy patients; however, surgeon experience as well as individual patient factors play important roles when deciding upon the surgical approach.

Current status of robot-assisted minimally invasive esophagectomy: what is the real benefit?

Robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer has been performed increasingly frequently over the last few years. Robotic systems with articulated devices and tremor filtration allow surgeons to perform such procedures more meticulously than by hand. The feasibility of RAMIE has been demonstrated in several retrospective comparative studies, which showed similar short-term outcomes to conventional minimally invasive esophagectomy (cMIE). Considering the number of harvested lymph nodes, RAMIE may be superior to cMIE in terms of left upper mediastinal lymph node dissection. However, whether or not the addition of a robotic system to cMIE can help improve perioperative and oncological outcomes remains unclear. Given the lack of established evidence from randomized controlled trials, we must await the results of ongoing studies to reach any meaningful conclusions. Further advancements in robotic platforms, as well as the reduction in medical expenses, will be essential to demonstrate the real benefit of RAMIE.

Impact of Minimally Invasive Esophagectomy in Post-Operative Atrial Fibrillation and Long-Term Mortality in Patients Among Esophageal Cancer

Aims:

Postoperative Atrial fibrillation (POAF) after esophagectomy may prolong stay in intensive care and increase risk of perioperative complications. A minimally invasive approach is becoming the preferred option for esophagectomy, yet its implications for POAF risk remains unclear. The association between POAF and minimally invasive esophagectomy (MIE) was examined in this study.

Methods:

We used a dataset of 575 patients who underwent esophagectomy. Multivariate logistic regression analysis was performed to examine the association between MIE and POAF. A cox proportional hazards model was applied to assess the long-term mortality (MIE vs open esophagectomy, OE).

Results:

Of the 575 patients with esophageal cancer, 62 developed POAF. MIE was negatively associated with the occurrence of POAF (Odds ratio: 0.163, 95%CI: 0.033-0.801). No significant difference was observed in long-term mortality (Odds ratio: 2.144, 95%CI: 0.963-4.775).

Conclusions:

MIE may reduced the incidence of POAF without compromising the survival of patients with esophageal cancer. Moreover, the specific mechanism of MIE providing this possible advantage needs to be determined by larger prospective cohort studies with specific biomarker information from laboratory tests.

Does robot-assisted minimally invasive oesophagectomy have superiority over thoraco-laparoscopic minimally invasive oesophagectomy in lymph node dissection?

Although robotic techniques have been used for oesophagectomy for many years, whether robot-assisted minimally invasive oesophagectomy (RAMIE) can actually improve outcomes and surpass thoraco-laparoscopic minimally invasive oesophagectomy (MIE) in the success rate of lymph node dissection remains to be empirically demonstrated. Therefore, we performed this systematic review and meta-analysis of case-control studies to systematically compare the effect of lymph node dissection and the incidence of vocal cord palsy between RAMIE and MIE. The PubMed, EMBASE, and Web of Science databases were systematically searched up to December 1, 2019, for case-control studies that compared RAMIE with MIE. Thirteen articles were included, with a total of 1,749 patients with esophageal cancer, including 866 patients in the RAMIE group and 883 patients in the MIE group. RAMIE yielded significantly larger numbers of total dissected lymph nodes (WMD = 1.985; 95% CI, 0.448-3.523; P = 0.011) and abdominal lymph nodes (WMD = 1.686; 95% CI, 0.420-2.951; P = 0.009) as well as lymph nodes along RLN (WMD = 0.729; 95% CI, 0.348-1.109; P < 0.001) than MIE. Additionally, RAMIE could significantly decrease estimated blood loss (WMD = -11.208; 95% CI, -19.358 to -3.058; P = 0.007) and the incidence of vocal cord palsy (OR = 0.624; 95% CI, 0.411-0.947; P = 0.027) compared to MIE. Compared with MIE, RAMIE resulted in a higher total lymph node yield and a higher lymph node yield in the abdomen and along RLN, along with reduced blood loss during surgery and the incidence of vocal cord palsy. Therefore, RAMIE could be considered to be a standard treatment, with less blood loss, lower incidence of vocal cord palsy, and more radical lymph node dissection, exhibiting superiority over MIE.

State of the art in esophagectomy: robotic assistance in the abdominal phase

Over the years, robot-assisted esophagectomy gained popularity. The current literature focused mainly on robotic assistance in the thoracic phase, whereas the implementation of robotic assistance in the abdominal phase is lagging behind. Advantages of adding a robotic system to the abdominal phase include robotic stapling and the increased surgeon's independency. In terms of short-term outcomes and lymphadenectomy, robotic assistance is at least equal to laparoscopy. Yet high quality evidence to conclude on this topic remains scarce. This review focuses on the evidence of robotic assistance in the abdominal phase of esophagectomy.

Minimally invasive esophagectomy: clinical evidence and surgical techniques

Background

Surgical esophagectomy plays a crucial role in the curative and palliative treatment of esophageal cancer. Thereby, minimally invasive esophagectomy (MIE) is increasingly applied all over the world. Combining minimal invasiveness with improved possibilities for meticulous dissection, robot-assisted minimal invasive esophagectomy (RAMIE) has been implemented in many centers.

Purpose

This review focuses on the development of MIE as well as RAMIE and their value based on evidence in current literature.

Conclusion

Although MIE and RAMIE are highly complex procedures, they can be performed safely with improved postoperative outcome and equal oncological results compared with open esophagectomy (OE). RAMIE offers additional advantages regarding surgical dissection, lymphadenectomy, and extended indications for advanced tumors.

The role of surgery type in postoperative atrial fibrillation and in-hospital mortality in esophageal cancer patients with preserved left ventricular ejection fraction

BACKGROUND

Postoperative atrial fibrillation (POAF) is one of the most common complications of esophagectomy, which may extend the inpatient hospital stay. Minimally invasive esophagectomy (MIE) has been increasingly used in clinical practice; however, its POAF risk and short-term mortality remain unclear. This study aimed to examine the POAF risk and in-hospital mortality rate between patients receiving MIE and open esophagectomy (OE).

METHODS

Esophageal cancer patients who underwent MIE or OE from a retrospective cohort study were evaluated. A multivariate logistic regression model was built to assess the associations between esophagectomy (MIE vs. OE) and various outcomes (POAF, in-hospital mortality). Covariates included age, sex, body mass index, neoadjuvant therapy, tumor stage, surgery incision type, comorbidities, cardia conditions, peri-operative medication, and complications.

RESULTS

Of the 484 patients with esophageal cancer, 63 received MIE. A total of 53 patients developed POAF. Compared to patients receiving OE, MIE patients had 81% reduced odds of POAF (adjusted odds ratio [aOR] 0.185, 95% CI 0.039-0.887, P = 0.035). No statistically significant association was found for in-hospital mortality (aOR 0.709, 95% CI 0.114-4.409, P = 0.712).

CONCLUSIONS

MIE is associated with a lower risk of POAF, compared to traditional surgery. No significant short-term survival benefit was found for MIE.

Lymph node dissection and recurrent laryngeal nerve protection in minimally invasive esophagectomy

Until now, neoadjuvant therapy plus surgical resection of the primary tumor and potential metastatic lymph nodes (LNs) has been the current optimal treatment for locally advanced thoracic esophageal cancer (EC). LN metastasis is one of the most negative prognostic factors for thoracic esophageal squamous cell carcinoma (ESCC). However, the extent of LN dissection for thoracic ESCC has long been controversial worldwide. LNs along the recurrent laryngeal nerve (RLN) were reported to have the highest frequency of metastases in thoracic ESCC, so lymphadenectomy along the bilateral RLN is necessary but quite challenging because of a high frequency of recurrent nerve palsy and related postoperative complications. With the development of minimally invasive devices and techniques in recent years, minimally invasive esophagectomy (MIE) has been widely applied in EC surgery. The topics of what the optimal extent of lymphadenectomy is and how the recurrent nerve should be well protected during MIE have been debated in recent years. The purpose of our review is specifically to address the patterns of LN metastasis, the extent of LN dissection, and the protection of the RLN in MIE for thoracic ESCC.

Reflux Disease and Adenocarcinoma of the Esophagus and Cardia: Global Management and Surgical Treatment

Introduction: Adenocarcinoma of the esophagus and cardia is a rare cancer, associated with chronic reflux disease. Its associated mortality is still very high, reflecting both aggressive biology and lack of adequate treatments. The aim of this article was to describe up to date management of these complex tumors. Materials and Methods: A systematic review of the literature was performed, using PubMed Central database. Articles published after the year 2000 were included, with no language exclusion. Results: Reflux disease and Barrett esophagus are strongly associated with esophageal adenocarcinoma. A strict surveillance should be initiated at diagnosis. Both proton pump inhibitors and antireflux surgery failed to influence the incidence of cancer. Surgery and multimodal therapies are keystones for curative treatment, but no clear consensus exists for the best option. A clear trend in standardization of the surgical approach is observed since last ten years. However, the optimal approach for the tumors of the cardia is still not completely set. Complication rate is still high, but real progresses are made, through the implementation of less invasive techniques. Conclusion: Progress has been made in the management of esophageal cancer. However, the multiplicity of choices failed to lead to standardization. The development of international consensus regarding multimodal treatment and surgical approaches is needed.

Innovative fully robotic 4-arm Ivor Lewis esophagectomy for esophageal cancer (RAMIE4)

Nowadays robotic surgery is established for abdominal and thoracic surgery. It has been shown that complex procedures are feasible using robotic systems, e.g., da Vinci Xi, with a huge benefit in precision. Different techniques for esophageal cancer surgery are reported; however, only a few robotic and partial robotic procedures are described. Therefore, a fully robotic (abdominal and thoracic) Ivor Lewis esophageal resection using four robotic arms-RAMIE4-the standard technique used for lower esophageal cancer, is presented in this paper. The technique shown in the video was performed successfully in 100 cases in 24 months. The reconstruction is performed with a gastric conduit pull-up and intrathoracic manually inserted 28-mm circular end-to-side stapled anastomosis. This video demonstrates the feasibility of RAMIE4 in the abdomen and thorax and reveals advantages of the robotic assistance.

Comparisons of short-term outcomes between robot-assisted and thoraco-laparoscopic esophagectomy with extended two-field lymph node dissection for resectable thoracic esophageal squamous cell carcinoma

Background

Video-assisted thoracoscopic surgery has been identified as priori choice compared with open approaches in esophageal cancer surgery. With the developments in the Da Vinci robotic system, the robot-assisted minimally invasive esophagectomy (RAMIE) has been increasingly popular. However, whether RAMIE could be a better choice over thoraco-laparoscopic minimally invasive esophagectomy (TLMIE) is unclear.

Methods

The clinicopathological characteristics of patients who received RAMIE or TLMIE with modern two-field lymph node dissection in Sun Yat-sen University Cancer Center between Jan 2016 to Jan 2018 were retrospectively retrieved. The 1:1 propensity score match analysis was performed to compare the short-term effectiveness and safety between the two groups.

Results

Two hundred and fifteen esophageal squamous cell carcinoma (ESCC) patients received RAMIE (101 patients) or TLMIE (114 patients) were included in the analysis. After a 1:1 propensity score matching, 108 patients (54 pairs) who received RAMIE or TLMIE displayed no significant variance in baseline clinicopathological characteristics. No significant difference in operative time, intraoperative blood loss, number of resected lymph nodes, and R0 resection rates were observed between the matched groups. However, the recurrent laryngeal nerve protection was better in RAMIE group (P=0.021). Nevertheless, both the incidences of common postoperative complications and length of ICU (hospital) stay were similar in two groups. The average total (P=0.009) and daily (P=0.028) expenses of RAMIE were higher.

Conclusions

In general, RAMIE could benefit patients by providing better recurrent laryngeal nerve protection. In order to promote the applications of RAMIE, more efforts should be made to reduce the costs by the social and medical insurance agencies.

Robot-assisted minimally invasive esophagectomy (RAMIE) improves perioperative outcomes: a review

Robotic assisted minimal invasive esophagectomy (RAMIE) is increasingly applied as a clinically and oncologically safe technique in the surgical treatment of esophageal cancer. This review focuses on the advantages and potential opportunities of RAMIE to improve the perioperative and oncological outcomes based on the evidence from current literature. In addition, critical notes on aspects such as procedure duration and costs are addressed in this paper.

Reducing pulmonary complications after esophagectomy for cancer

The cornerstone of curative care for esophageal cancer is neoadjuvant chemoradiotherapy followed by esophagectomy with a radical lymphadenectomy. An esophagectomy is a major and complex surgical procedure and is often followed by postoperative morbidity, especially pulmonary complications. These complications may lead to an increase in hospital stay, intensive care unit admission rate and mortality. Therefore, perioperative strategies to reduce these complications have been investigated and implemented in clinical practice. In this review we highlight the influence of minimally invasive surgery, postoperative pain management, early identification of complications and the usage of uniform definitions on (pulmonary) complications after esophagectomy. Finally, we will discuss some future perspectives.

Robotic-assisted minimally invasive oesophagectomy for cancer: An initial experience

Background:

The morbidity related to radical oesophagectomy can be reduced by adopting minimally invasive techniques. Over 250 thoraco-laparoscopic oesophagectomy (TLE) was done in our centre over the last 15 years, before adopting robotic surgery as the latest innovation in the field of minimally invasive surgery. Here, we share our initial experience of robotic-assisted minimally invasive oesophagectomy (RAMIE) for carcinoma oesophagus.

Methods:

A prospective observational study conducted from February to December 2017. A total of 15 patients underwent RAMIE in this period. Data regarding demography, clinical characteristics, investigations, operating techniques, and post-operative outcome were collected in detail.

Results:

There were 10 (66.7%) male patients and the median age of all patients was 62.9 (range 36–78) years. The median body mass index was 24.4 (range 15–32.8) kg/m². Twelve (80.0%) patients had squamous cell carcinoma (SCC) of the oesophagus and 3 (20%) patients had adenocarcinoma (AC). Five (33.3%) patients received neoadjuvant therapy. All 15 patients underwent RAMIE. Patients with SCC underwent McKeown's procedure, and those with AC underwent Ivor Lewis procedure. Extended two-field lymphadenectomy (including total mediastinal lymphadenectomy) was done for all the patients. The median operating time was 558 (range 390–690) min and median blood loss was 145 (range 90–230) ml. There were no intra-operative adverse events, and none of them required conversion to open or total thoracolaparoscopic procedure. The most common post-operative complications were recurrent laryngeal nerve paresis (3 patients, 20.0%) and pneumonia (2 patients, 13.3%). The median hospital stay was 9 (range 7–33) days. In total, 9 (60%) patients required adjuvant treatment.

Conclusion:

Adequate experience in TLE can help minimally invasive surgeons in easy adoption of RAMIE with satisfactory outcome.

Minimally invasive esophagectomy: a propensity score-matched analysis of semiprone versus prone position

BACKGROUND

The preferred surgical approach for esophageal cancer is a minimally invasive transthoracic esophagectomy with a two-field lymph node dissection. The thoracoscopic phase may be performed either in prone- or in left lateral decubitus (LLD) position. Prone positioning has been associated with better pulmonary outcomes compared to LLD positioning; however, conversion to a classic thoracotomy is more difficult. The semiprone position has been proposed as an alternative approach.

METHODS

A retrospective review of a prospectively maintained database (2008-2014) was performed to compare postoperative complications, surgical radicality, and lymph node yield between patients who underwent three-stage minimally invasive transthoracic esophagectomy in either the prone or semiprone position. Comparative analyses were conducted before and after propensity score matching.

RESULTS

One hundred and twenty-one patients were included. In total, 82 patients underwent minimally invasive esophagectomy (MIE) in semiprone position and 39 patients in prone position. After propensity score matching, both groups consisted of 39 patients. The operative time in the semiprone group was longer (368 vs. 225 min, P < 0.001) and in this group the lymph node yield was significantly higher (16 (range 6-80) vs. 13 (range 3-33), P = 0.019). There were no statistically significant differences regarding radical resections, postoperative complications, and hospital stay.

CONCLUSION

The use of semiprone positioning in MIE is safe, feasible, and at least comparable to MIE in prone position in terms of oncological clearance and postoperative complications.

Early experience with totally robotic esophagectomy for malignancy. Surgical and oncological outcomes

BACKGROUND

Over recent decades, minimally invasive esophagectomy has gained popularity and is increasingly performed worldwide. The aim of this work was to investigate the perioperative, clinicopathologic, and oncological outcomes of robot-assisted esophagectomy on a consecutive series of totally robotic procedures.

METHODS

All patients received either an Ivor Lewis or a McKeown procedure according to tumor location. Perioperative, clinicopathologic and oncological outcomes were examined.

RESULTS

A total of 38 patients underwent robot-assisted esophagectomy procedures. All underwent surgery for primary esophageal neoplasms. Neoadjuvant therapy was given to 22 patients. R0 resections were achieved in all patients and no conversion to open surgery occurred. Overall morbidity and mortality were 42% and 10%, respectively. The 1 year disease free survival was 78.9%, whereas the 1 year overall survival was 84.2%.

CONCLUSIONS

Robotic surgery can be employed to treat esophageal malignancy competently. Robotic esophagectomy satisfies all features of pathologic appropriateness and offers the expected oncological results.

Mediastinal lymphadenectomy for esophageal cancer: Differences between two countries, Japan and the Netherlands

Extent of mediastinal lymphadenectomy during esophagectomy is clearly different between two representative countries of the Eastern and Western world, such as Japan and the Netherlands. In Japan, a clear policy is the standard complete two- or three-field type of lymphadenectomy whereas, in the Netherlands, a limited form is usually carried out. Reasons for these differences can be found in the different types of tumor, 80% of adenocarcinomas in the West and almost 95% of squamous cell cancer in Japan. Moreover, location of the tumors, distally located in the Netherlands whereas, in Japan, the majority are located in the middle and proximal thoracic esophagus. Also, type of neoadjuvant therapy, namely chemoradiotherapy in the Netherlands, and chemotherapy in Japan, are different. Arguments for more extended mediastinal lymphadenectomy are currently challenged in the West, first by the systematic use of chemoradiotherapy as neoadjuvant therapy and, second, the retrospective analysis of large data. According to two studies, the importance of extended lymphadenectomy is shown to be relative and less clear, especially in esophageal adenocarcinomas after neoadjuvant therapy. International efforts such as the TIGER study will help to standardize and find a relationship between the type and location of esophageal cancer, use of neoadjuvant therapy, extent of lymphadenectomy and survival.

Surgical anatomy of the omental bursa and the stomach based on a minimally invasive approach: different approaches and technical steps to resection and lymphadenectomy

BACKGROUND

It is imperative for surgeons to have a proper knowledge of the omental bursa in order to perform an adequate dissection during minimally invasive surgery (MIS) of the upper gastrointestinal (GI) tract. This study aimed to describe (1) the various approaches which can be used to enter the bursa and to perform a complete lymphadenectomy, (2) the boundaries and anatomical landmarks of the omental bursa as seen during MIS, and (3) whether a bursectomy should be performed for oncological reasons in upper GI cancer.

METHODS

In this observational study, videos of 20 patients undergoing different MIS procedures were reviewed, and the findings were verified prospectively in 5 patients undergoing a total gastrectomy and in a transversely sectioned cadaver. A systematic literature review (PubMed) was performed on the additive value of bursectomy during gastrectomy for cancer.

RESULTS

The omental bursa can be surgically entered through the hepatogastric ligament, gastrocolic ligament, gastrosplenic ligament or through the transverse mesocolon. Anatomical boundaries of the omental bursa could be clearly identified, and new anatomical landmarks were described (gastro-omental folds). The cranial part of the omental bursa consists of two compartments (splenic recess and superior recess), separated by the gastropancreatic fold, communicating at the level of the pancreas, and extending distally as the inferior recess. There is no clear evidence regarding beneficial effect of a bursectomy in upper GI oncology.

CONCLUSIONS

The description of the omental bursa in this study may help surgeons perform a more adequate oncological dissection during MIS. Bursectomy should not be routinely performed during oncological resections.