Robotically assisted laparoscopic transhiatal esophagectomy

Is Robotic Surgery the Future for Resectable Esophageal Cancer?: A Systematic Literature Review of Oncological and Clinical Outcomes

BACKGROUND

Radical esophagectomy for resectable esophageal cancer is a major surgical intervention, associated with considerable postoperative morbidity. The introduction of robotic surgical platforms in esophagectomy may enhance advantages of minimally invasive surgery enabled by laparoscopy and thoracoscopy, including reduced postoperative pain and pulmonary complications. This systematic review aims to assess the clinical and oncological benefits of robot-assisted esophagectomy.

METHODS

A systematic literature search of the MEDLINE (PubMed), Embase and Cochrane databases was performed for studies published up to 1 August 2023. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols and was registered in the PROSPERO database (CRD42022370983). Clinical and oncological outcomes data were extracted following full-text review of eligible studies.

RESULTS

A total of 113 studies (n = 14,701 patients, n = 2455 female) were included. The majority of the studies were retrospective in nature (n = 89, 79%), and cohort studies were the most common type of study design (n = 88, 79%). The median number of patients per study was 54. Sixty-three studies reported using a robotic surgical platform for both the abdominal and thoracic phases of the procedure. The weighted mean incidence of postoperative pneumonia was 11%, anastomotic leak 10%, total length of hospitalisation 15.2 days, and a resection margin clear of the tumour was achieved in 95% of cases.

CONCLUSIONS

There are numerous reported advantages of robot-assisted surgery for resectable esophageal cancer. A correlation between procedural volume and improvements in outcomes with robotic esophagectomy has also been identified. Multicentre comparative clinical studies are essential to identify the true objective benefit on outcomes compared with conventional surgical approaches before robotic surgery is accepted as standard of practice.

[Evidence for Minimal Invasive Oesophageal Resection]

In the course of the last 20 years, minimally invasive therapy has become much more important in all areas. In particular, surgical procedures have been established in oncological surgery, even without generating the necessary evidence to assure that the quality is equal to that achieved with open procedures. For this purpose, it has only been in recent years that appropriate randomised controlled studies followed by meta-analyses have been carried out. In this article, we summarise the evidence for minimally invasive resection of the oesophagus and review current literature for each procedure.

Transhiatal robot-assisted minimally invasive esophagectomy: unclear benefits compared to traditional transhiatal esophagectomy

Esophagectomy is a high-risk operation, regardless of technique. Minimally invasive transthoracic esophagectomy could reduce length of stay and pulmonary complications compared to traditional open approaches, but the benefits of minimally invasive transhiatal esophagectomy are unclear. We performed a retrospective review of prospectively gathered data for open transhiatal esophagectomies (THEs) and transhiatal robot-assisted minimally invasive esophagectomies (TH-RAMIEs) performed at a high-volume academic center between 2013 and 2017. Multivariate logistic regression was used to calculate adjusted odds ratios (aORs) for outcomes. 465 patients met inclusion criteria (378 THE and 87 TH-RAMIE). THE patients more likely had an ASA score of 3 + (89.1% vs 77.0%, p = 0.012), whereas TH-RAMIE patients more likely had a pathologic staging of 3+ (43.7% vs. 31.2%, p = 0.026). TH-RAMIE patients were less likely to receive epidurals (aOR 0.06, 95% confidence interval [CI] 0.03-0.14, p < 0.001), but epidural use itself was not associated with differences in outcomes. TH-RAMIE patients experienced higher rates of pulmonary complications (adjusted odds ratio [OR] 1.82, 95% CI 1.03-3.22, p = 0.040), particularly pulmonary embolus (aOR 5.20, 95% CI 1.30-20.82, p = 0.020). There were no statistically significant differences in lymph node harvest, unexpected ICU admission, length of stay, in-hospital mortality, or 30-day readmission or mortality rates. The TH-RAMIE approach had higher rates of pulmonary complications. There were no statistically significant advantages to the TH-RAMIE approach. Further investigation is needed to understand the benefits of a minimally invasive approach to the open transhiatal esophagectomy.

Robot-Assisted Thoracoscopic Esophagectomy with Total Mediastinal Lymphadenectomy: A Guide to a Systematic Approach Using the Concept of Fascial Plane Dissection

Recent case series and meta-analyses have suggested that robot-assisted minimally invasive esophagectomy (RAMIE) could be a useful alternative to video-assisted thoracic surgery esophagectomy. The advantages of RAMIE are a 3-dimensional view, 7 degrees of freedom, and tremor filtering, which enable more meticulous lymph node dissection with a lower incidence of complications. However, in radical esophagectomy, understanding the concepts of the fascia and compartment is crucial for successful and reliable dissection. The first RAMIE in Korea was performed by our team in July 2006, and since then, we have developed related techniques to achieve better short- and long-term outcomes. The key step in RAMIE for esophageal squamous cell carcinoma is dissection of the upper mediastinum due to the difficulty of lymph node dissection and the high incidence of nodal metastasis in the area. Herein, we describe the technique of fascial plane dissection with esophageal suspension during RAMIE.

Novel Transgastric Endoluminal Segmental Esophagectomy and Primary Anastomosis Technique: A Hybrid Transgastric Thoracoscopic Esophagectomy for the Treatment of High Grade Dysplasia and Early Esophageal Cancer in a Porcine Ex vivo Model

Multiple modalities are currently employed in the treatment of high grade dysplasia and early esophageal carcinoma. While they are the subject of ongoing investigation, surgery remains the definitive modality for oncological resection. Esophagectomy, however, is traditionally a challenging surgical procedure and carries a significant incidence of morbidity and mortality. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are considerably less invasive alternatives to esophagectomy in the diagnosis and treatment of high grade dysplasia, early esophageal squamous cell carcinoma and adenocarcinoma. However, many early esophageal cancer patients, with favorable histology, who could benefit from endoscopic resection, are referred for formal esophagectomy due to lesion characteristics such as unfavorable lesion morphology or recurrence after previous endoscopic resection. In this study we present a novel, hybrid thoracoscopic transgastric endoluminal segmental esophagectomy with primary anastomosis for the potential treatment of high grade dysplasia and early esophageal cancer in a porcine ex vivo model as a proposed bridge between endoscopic resection and the relatively high mortality and morbidity formal esophagectomy procedure. The novel technique consists of thoracoscopic esophageal mobilization in addition to transgastric endoluminal segmental esophagectomy and anastomosis utilizing a standard circular stapler. The technique was found feasible in all experimental subjects. The minimally invasive nature of this novel procedure as well as the utility of basic surgical equipment and surgical skill is an important attribute of this method and can potentially make it a treatment option for many patients who would otherwise be referred for a formal esophagectomy.

Long-term outcomes after robotic-assisted Ivor Lewis esophagectomy

Robotic assistance has gained acceptance in thoracic procedures, including esophagectomy. There is a paucity of data regarding long-term outcomes for robotic esophagectomy. We previously reported our initial series of robot-assisted Ivor Lewis (RAIL) esophagectomy. We report long-term outcomes to assess the efficacy of the procedure. We performed a retrospective review of 112 consecutive patients who underwent a RAIL. Patient demographics, diagnosis, pathology, operative characteristics, post-operative complications, and long-term outcomes were documented. Descriptive statistical analysis was performed for all the variables. Primary endpoints were mortality and disease-free survival. Overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. Of the 112 patients, 106 had a diagnosis of cancer, with adenocarcinoma the dominant histology (87.5%). Of these 106 patients, 81 (76.4%) received neo-adjuvant chemoradiation. The 30-, 60-, and 90-day mortality was 1 (0.9%), 3 (2.7%), and 4 (3.6%), respectively. There were 9 anastomotic leaks (8%) and 18 (16.1%) patients had a stricture requiring dilation. All-patient OS at 1, 3, and 5 years was 81.4%, 60.5%, and 51.0%, respectively. For cancer patients, the 1-, 3-, and 5-year OS was 81.3%, 59.2%, and 49.4%, respectively, and the DFS was 75.3%, 42.3%, and 44.0%. We have shown that long-term outcomes after RAIL esophagectomy are similar to other non-robotic esophagectomies. Given the potential advantages of robotic assistance, our results are crucial to demonstrate that RAIL does not result in inferior outcomes.

Robotic transhiatal esophagectomy

Horgan et al. described the first robotic-assisted transhiatal esophagectomy in 2003. Although there is debate regarding the oncologic appropriateness of transhiatal versus thoracic approach to esophagectomy in malignancy, comparative data are still lacking. This paper with video describes step by step how and when to perform a transhiatal robotic-assisted resection in patients with esophageal cancer.

Robotic resection for esophageal cancer

Background

In the surgical treatment of esophageal cancer, complete tumor resection is the most important factor and determines long-term survival. With an increase in robotic expertise in other fields of surgery, robotic-assisted minimally invasive esophagectomy (RAMIE) was born. Currently, there is a lack of convincing data on the extent of expected benefits (perioperative and oncologic outcomes and/or quality of life). Some evidence exists that patients’ overall quality of life and physical function improves, with less fatigue and pain 3 months after surgery. We aimed to review the available literature regarding robotic esophagectomy, compare perioperative, oncologic, and quality of life outcomes with open and minimally invasive approaches, and give a brief overview of our standardized four-arm RAMIE technique and explore future directions.

Methods

A Medline (PubMed) search was conducted including the following key words: esophagectomy, minimally invasive esophagectomy, robotic esophagectomy, Ivor Lewis and McKeown. We present the history, different techniques used, outcomes, and the standardization of robotic esophagectomy.

Results

Robotic esophagectomy offers a steeper learning curve with fewer complications but comparable oncological results compared to conventional minimally invasive esophagectomy.

Conclusions

Available studies suggest that RAMIE is associated with benefits regarding length of stay, clinical outcomes, and quality of life—if patients are treated in an experienced center with a standardized technique for robotic esophagectomy—making it a potentially beneficial tool in the treatment of esophageal cancer. However, center-wide standardization and prospective data collection will be a necessity to prove superiority of robotic esophagectomy.

THE Big Deal: An Institution's Experience with Robotic Transhiatal Esophagectomy

As minimally invasive operations evolve, it is imperative to evaluate the advantages and risks involved. The aim of our study was to evaluate our institution's experience in incorporating a robotic platform for transhiatal esophagectomy (THE). Patients undergoing robotic THE were prospectively followed. Data are presented as median (mean ± SD). Forty-five patients were of 67 (67 ± 6.9) years and BMI 26 (27 ± 5.5) kg/m2. Nine per cent of operations were converted to “open,” but none in the last 25 operations. Operative duration of robotic THE was 334 (364 ± 108.8) minutes and estimated blood loss was 200 (217 ± 144.0) mL, which decreased with time ( P = 0.017). Length of stay was 8 (12 ± 11.1) days. Twenty per cent had respiratory failure requiring intubation that resolved, 4 per cent developed pneumonia, 11 per cent developed a surgical site infection, 2 per cent developed renal insufficiency, and 2 per cent developed a UTI. Two per cent (one patient) died within 30 days postoperatively, because of cardiac arrest. Our experience with robotic THE promotes robotic application because we endeavor to achieve high-level proficiency. With experience, we improved estimated blood loss and converted fewer transhiatal esophagectomies to “open.” Our length of hospital stay seems long but reflects the ill-health of patients, as does the variety of complications. Our data support the evolving future of THE, which will integrally include a robotic approach.

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.

Oncologic Resection in Laparoscopic Versus Robotic Transhiatal Esophagectomy

Background and Objectives:

As the use of robotic surgery continues to increase, little is known about robotic oncologic outcomes compared with traditional methods in esophagectomy. The aim of this study was to examine the perioperative oncologic outcomes of patients undergoing laparoscopic versus robot-assisted transhiatal esophagectomy (THE).

Methods:

Thirty-six consecutive patients who underwent laparoscopic and robot-assisted THE for malignant disease over a 3-year period were identified in a retrospective database. Eighteen patients underwent robotic-assisted THE with cervical anastomosis, and 18 patients underwent laparoscopic THE. All procedures were performed by a single foregut and thoracic surgeon.

Results:

Patient demographics were similar between the 2 groups with no significant differences. Lymph node yields for both laparoscopic and robot-assisted THE were similar at 13.9 and 14.3, respectively (P = .90). Ninety-four percent of each group underwent R0 margins, but only 1 patient from each modality had microscopic positive margins. All of the robot-assisted patients underwent neoadjuvant chemoradiation, whereas 83.3% underwent neoadjuvant therapy in the laparoscopy group (P = .23). Clinical and pathologic stagings were similar in each group. There was 1 death after laparoscopic surgery in a cirrhotic patient and no mortalities among the robot-assisted THE patients (P = .99). One patient from each group experienced an anastomotic leak, but neither patient required further intervention.

Conclusions:

Laparoscopic and robot-assisted THEs yield similar perioperative oncologic results including lymph node yield and margin status. In the transition from laparoscopic surgery, robotic surgery should be considered oncologically noninferior compared with laparoscopy.

Comparative outcomes of minimally invasive and robotic-assisted esophagectomy

OBJECTIVE

Minimally invasive esophagectomy (MIE) has demonstrated superior outcomes compared to open approaches. The myriad of techniques has precluded the recommendation of a standard approach. The addition of robotics to esophageal resection has potential benefits. We sought to examine the outcomes with MIE to include robotics.

METHODS

Utilizing a prospective esophagectomy database, we identified patients who underwent (MIE) Ivor Lewis via thoracoscopic/laparoscopic (TL), transhiatal (TH), or robotic-assisted Ivor Lewis (RAIL). Patient demographics, tumor characteristics, and complications were analyzed via ANOVA, χ², and Fisher exact where appropriate.

RESULTS

We identified 302 patients who underwent MIE: TL 95 (31.5%), TH 63 (20.8%), and RAIL 144 (47.7%) with a mean age of 65 ± 9.6. The length of operation was longer in the RAIL: TL (299 ± 87), TH (231 ± 65), RAIL (409 ± 104 min), p < 0.001. However, the EBL was lower in the patients undergoing transthoracic approaches (RAIL + TL): TL (189 ± 188 ml), TH (242 ± 380 ml), RAIL (155 ± 107 ml), p = 0.03. Conversion to open was also lower in these patients: TL 7 (7.4%), TH 8 (12.7%), RAIL 0, p < 0.001. The R0 resection rate and lymph node (LN) harvest also favored the RAIL cohort: TL 86 (93.5%), TH 60 (96.8%), and RAIL 144 (100%), p = 0.01; LN: TL 14 ± 7, TH 9 ± 6, and RAIL 20 ± 9, p < 0.001. The overall morbidity was lower in MIE patients that underwent a transthoracic approach vs. transhiatal: TL 29 (30.5%), TH 39 (61.9%), RAIL 34 (23.6%), p < 0.001.

CONCLUSIONS

Patients undergoing MIE via thoracoscopic/laparoscopic and robotic transthoracic approaches demonstrated lower EBL, morbidity, and conversion to open compared to the transhiatal approach. Additionally the oncologic outcomes measured by R0 resections and LN harvest also favored the patients who underwent a transthoracic approach.

Minimally Invasive and Robotic Esophagectomy: A Review

Great advances have been made in the surgical management of esophageal disease since the first description of esophageal resection in 1913. We are in the era of minimally invasive esophagectomy. The current three main approaches to an esophagectomy are the Ivor Lewis technique, McKeown technique, and the transhiatal approach to esophagectomy. These operations were associated with a high morbidity and mortality. The recent advances in minimally invasive surgical techniques have greatly improved the outcomes of these surgical procedures. This article reviews the literature and describes the various techniques available for performing minimally invasive esophagectomy and robot-assisted esophagectomies, the history behind the development of these techniques, the variations, and the contemporary outcomes after such procedures.

Initial experience of robot-assisted Ivor-Lewis esophagectomy: 61 consecutive cases from a single Chinese institution

This study aims to report the technical details and preliminary outcomes of robot-assisted Ivor-Lewis esophagectomy (RAILE) using two different types of intrathoracic anastomosis from a single institution in China. From May 2015 to October 2017, 61 patients diagnosed with mid-lower esophageal cancer were treated with RAILE. The RAILE procedure was performed in two stages. The first 35 patients underwent circular end-to-end stapled intrathoracic anastomosis (stapled group), and the remaining 26 patients had a double-layered, completely hand-sewn intrathoracic anastomosis (hand-sewn group). Patient characteristics, surgical techniques, postoperative complications, and pathology outcomes were analyzed. The mean operating time and mean blood loss were 315.6 ± 59.4 minutes and 189.3 ± 95.8 mL, respectively. There was one patient who underwent conversion to thoracotomy. The 30-day and in-hospital mortality rates were 0%. Overall complications were observed in 22 patients (36.1%) according to the Clavien-Dindo (CD) and the Esophagectomy Complications Consensus Group (ECCG) classifications, of whom 6 patients (9.8%) had anastomotic leakage (ECCG, Type II). The median length of hospitalization (LOH) was 10 days (IQR, 5 days). Complete (R0) resection was achieved in all cases. The mean tumor size was 3.2 ± 1.5 cm, and the mean number of totally dissected lymph nodes was 19.3 ± 9.2. Regarding the operative outcomes between stapled and hand-sewn groups, there were no significant differences in the operative time (325.4 ± 66.6 vs. 302.3 ± 45.9 min, P = 0.114), blood loss (172.9 ± 74.1 vs. 211.5 ± 117.0 mL, P = 0.147), conversion rate (2.9 vs. 0%, P = 1.000), overall complication rate (37.1 vs. 34.6%, P = 0.839) or LOH (10 vs. 9.5 days, P = 0.415). RAILE using both stapled and hand-sewn intrathoracic anastomosis is safe and technically feasible with satisfactory perioperative outcomes for the treatment of mid-lower thoracic esophageal cancer.

Comparison of short-term outcomes between robot-assisted minimally invasive esophagectomy and video-assisted minimally invasive esophagectomy in treating middle thoracic esophageal cancer

Whether the robot-assisted minimally invasive esophagectomy (RAMIE) has any advantages over the video-assisted minimally invasive esophagectomy (VAMIE) remains controversial. In this study, we tried to compare the short-term outcomes of RAMIE with that of VAMIE in treating middle thoracic esophageal cancer from a single medical center. Consecutive patients undergoing RAMIE or VAMIE for middle thoracic esophageal cancer from April 2016 to April 2017 were prospectively included for analysis. Baseline data and pathological findings as well as short-term outcomes of these two group (RAMIE group and VAMIE group) patients were collected and compared. A total of 84 patients (RAMIE group: 42 patients; VAMIE group: 42 patients) were included for analysis. The baseline characteristics between the two groups were comparable. RAMIE yielded significantly larger numbers of total dissected lymph nodes (21.9 and 17.8, respectively; P = 0.042) and the right recurrent laryngeal nerve (RLN) lymph nodes (2.1 and 1.2, respectively; P = 0.033) as well as abdominal lymph nodes (10.8 and 7.7, respectively; P = 0.041) than VAMIE. Even though RAMIE may consume more overall operation time, it could significantly decrease total blood loss compared to VAMIE (97 and 161 mL, respectively; P = 0.015). Postoperatively, no difference of the risk of major complications or hospital stay was observed between the two groups. In conclusion, RAMIE had significant advantage of lymphadenectomy especially for dissecting RLN lymph nodes over VAMIE with a comparable rate of postoperative complications. Further randomized controlled trials are badly needed to confirm and update our conclusions.

Safety and feasibility of robotic-assisted Ivor-Lewis esophagectomy

Esophagectomy is associated with substantial morbidity. Robotic surgery allows complex resections to be performed with potential benefits over conventional techniques. We applied this technology to transthoracic esophagectomy to assess safety, feasibility, and reliability of this technology. A retrospective cohort study of all patients undergoing robotic-assisted Ivor-Lewis esophagectomy (RAIL) from 2009 to 2014 was conducted. Clinicopathologic factors and surgical outcomes were recorded and compared. All statistical tests were two-sided and a P-value of <0.05 was considered statistically significant. We identified 147 patients with an average age 66 ± 10 years. Neoadjuvant therapy was administered to 114 (77.6%) patients, and all patients underwent a R0 resection. The mean operating room (OR) time was 415 ± 84.6 minutes with a median estimated blood loss (EBL) of 150 (25-600) mL. Mean intensive care unit (ICU) stay was 2.00 ± 4.5 days, median length of hospitalization (LOH) was 9 (4-38) days, and readmissions within 90 days were low at 8 (5.5%). OR time decreased from 471 minutes to 389 minutes after 20 cases and a further decrease to mean of 346 minutes was observed after 120 cases. Complications occurred in 37 patients (25.2%). There were 4 anastomotic (2.7%) leaks. Thirty and 90-day mortality was 0.68% and 1.4%, respectively. This represents to our knowledge the largest series of robotic esophagectomies. RAIL is a safe surgical technique that provides an alternative to standard minimally invasive and open techniques. In our series, there was no increased risk of LOH, complications, or death and re-admission rates were low despite earlier discharge.

Operative and survival outcomes in a series of 100 consecutive cases of robot-assisted transhiatal esophagectomies

Robotic-assisted transhiatal esophagectomy (RATE) is a technically complex procedure with potential for improved postoperative outcomes. In this report, we describe our experience with RATE in a large case series. A retrospective review was conducted to collect clinical, outcomes, and survival data for 100 consecutive patients with esophageal cancer (n = 98) and benign (n = 2) conditions undergoing RATE between March 2007 and December 2014. Progression-free (PFS) and overall (OS) survival were estimated using the Kaplan-Meier curves with comparisons by log-rank tests. Median operative time and estimated blood loss were 264 minutes and 75 mL, respectively. Median intensive care unit stay was 1 day and median length of hospital stay was 8 days. Postoperative complications commonly observed were nonmalignant pleural effusion (38%) and recurrent laryngeal nerve injury (33%); 30 day mortality rate was 2%. Median number of lymph nodes removed during RATE was 17 and R0 resection was achieved in 97.8% patients. At the end of the median follow-up period of 27.7 months, median PFS was 41 months and median OS was 54 months. 1-year and 3-year PFS rates were 82% (95% CI, 75%-89%) and 53% (95% CI, 42%-62%), respectively, and OS rates were 95% (95% CI, 91%-99%) and 57% (95% CI, 46%-67%). In our experience, RATE is an effective and safe oncologic surgical procedure in a carefully selected group of patients with acceptable operative time, minimal blood loss, standard postoperative morbidity and adequate PFS and OS profiles.

Robotic surgery for esophageal cancer: Merits and demerits

Since the introduction of robotic systems in esophageal surgery in 2000, the number of robotic esophagectomies has been gradually increasing worldwide, although robot‐assisted surgery is not yet regarded as standard treatment for esophageal cancer, because of its high cost and the paucity of high‐level evidence. In 2016, more than 1800 cases were operated with robot assistance. Early results with small series demonstrated feasibility and safety in both robotic transhiatal (THE) and transthoracic esophagectomies (TTE). Some studies report that the learning curve is approximately 20 cases. Following the initial series, operative results of robotic TTE have shown a tendency to improve, and oncological long‐term results are reported to be effective and acceptable: R0 resection approaches 95%, and locoregional recurrence is rare. Several recent studies have demonstrated advantages of robotic esophagectomy in lymphadenectomy compared with the thoracoscopic approach. Such technical innovations as three‐dimensional view, articulated instruments with seven degrees of movement, tremor filter etc. have the potential to outperform any conventional procedures. With the aim of preventing postoperative pulmonary complications without diminishing lymphadenectomy performance, a nontransthoracic radical esophagectomy procedure combining a video‐assisted cervical approach for the upper mediastinum and a robot‐assisted transhiatal approach for the middle and lower mediastinum, transmediastinal esophagectomy, was developed; its short‐term outcomes are promising.

Thus, the merits or demerits of robotic surgery in this field remain quite difficult to assess. However, in the near future, the merits will definitely outweigh the demerits because the esophagus is an ideal organ for a robotic approach.

A Mediastinoscopic Approach With Bilateral Cervicopneumomediastinum in Radical Thoracic Esophagectomy

We previously reported the performance of “mediastinoscopic esophagectomy with lymph node dissection” (MELD) under pneumomediastinum using a transcervical and transhiatal approach, as a method of radical esophagectomy. The procedure included the dissection of the left tracheobronchial lymph nodes (106tbL). We described our technique for dissecting the upper mediastinal lymph nodes. We revealed that the 106tbL lymph nodes were almost completely retrieved but that the upper thoracic paraesophageal lymph nodes (105) and the right recurrent nerve lymph nodes (106recR) were not completely retrieved. We are therefore of the opinion that a right cervical pneumomediastinal approach is necessary to achieve total dissection. We herein describe a case that was surgically treated using a bilateral cervicopneumomediastinal approach. A 68-year-old male patient was referred to our institution to undergo treatment for lower thoracic esophageal squamous cell carcinoma. The right recurrent nerve was first identified using an open approach. Pneumomediastinum was then initiated to allow for the 105 and 106recR lymph nodes to be completely dissected along the right mediastinal pleura, the right vagus nerve, the proximal portion of the azygos vein, and the right bronchial artery. The left recurrent nerve lymph nodes (106recL) and 106tbL lymph nodes were dissected as described previously. In order to perform bilateral upper mediastinal lymph node dissection and esophagectomy, a bilateral cervicopneumomediastinal approach is needed.

Mediastinoscopic subaortic and tracheobronchial lymph node dissection with a new cervico-hiatal crossover approach in thiel-embalmed cadavers

The use of mediastinal surgery for minimally invasive esophagectomy (MIE) has been proposed; however, this method is not performed as radical surgery because it has been thought to be impossible to perform complete upper mediastinal dissection, including the left tracheobronchial lymph nodes (106tbL). We herein describe a new method for performing complete dissection of the upper mediastinum. We developed a method for performing complete mediastinoscopic esophagectomy as radical surgery via the bilateral transcervical and transhiatal approach in 6 Thiel-embalmed human cadavers. The lower and middle mediastinal lymph nodes are dissected via the transhiatal approach. The dorsal side of the left recurrent nerve is dissected up to the aortic arch and left recurrent nerve lymph nodes (106recL) are dissected under pneumomediastinum. Next, the right recurrent nerve lymph nodes (106recR) are dissected. The cartilage of the left main bronchus is dissected and pushed downward, thereby obtaining a good view between the aortic arch and left main bronchus via the transhiatal approach. The 106tbL lymph nodes are dissected until the aortic arch is reached. Simultaneously, the lymph nodes are dissected via a right cervical incision. This method is termed the "cross-over technique." We herein demonstrated that the upper mediastinal lymph nodes, including the 106tbL nodes, can be dissected using the bilateral transcervical and transhiatal approach under pneumomediastinum and named this method "mediastinoscopic esophagectomy with lymph node dissection" (MELD). MELD is therefore considered to be a useful modality based on our experience with Thiel-embalmed human cadavers.

Robotic surgery for upper gastrointestinal cancer: Current status and future perspectives

Robotic surgery with the da Vinci Surgical System has been increasingly applied in a wide range of surgical specialties, especially in urology and gynecology. However, in the field of upper gastrointestinal (GI) tract, the da Vinci Surgical System has yet to be standard as a result of a lack of clear benefits in comparison with conventional minimally invasive surgery. We have been carrying out robotic gastrectomy and esophagectomy for operable patients with resectable upper GI malignancies since 2009, and have demonstrated the potential advantages of the use of the robot in possibly reducing postoperative local complications including pancreatic fistula following gastrectomy and recurrent laryngeal nerve palsy after esophagectomy, even though there have been a couple of problems to be solved including longer duration of operation and higher cost. The present review provides updates on robotic surgery for gastric and esophageal cancer based on our experience and review of the literature.

Three-field lymph node dissection in treating the esophageal cancer

There are many controversies in lymphadenectomy for thoracic esophageal cancer, and whether 3-field lymphadenectomy or 2-field lymphadenectomy is better have still been in doubt. The aim of this article is to review the role of the lymph node dissection by introducing the merits and demerits in 3-field lymphadenectomy, and the development in lymphadenectomy's selection, treatment and diagnosis. All the literatures related to esophageal lymphadenectomy and minimally invasive surgery (MIE) were searched in PubMed database and the cross references were added and reviewed to complete the reference list. Several researches elucidated that better overall survival (OS) in patients with esophageal cancer after 3-field lymphadenectomy had been reported worldwide, and 3-field lymphadenectomy is more suitable for treating esophageal cancer with cervical and/or upper mediastinal lymph nodes metastasis than 2-field lymphadenectomy regardless of the tumor's histology and location. Many approaches based on the characteristics of esophageal cancer lymph node metastasis are taken to improve the accuracy of 3-field lymphadenectomy and decrease the postoperative morbidity and mortality, while every approach needs further studies to demonstrate its feasibility. The benefits of the recently rapid-developed techniques performed in treating esophageal cancer: the MIE and the robotic-assisted thoracoscopic esophagectomy are illuminated as well, and both of them are technically safe and feasible for esophageal cancer, whereas further evaluations are still necessary.

Robotic Transhiatal Esophagectomy in a Community Hospital: Evolution of Technique

Esophageal cancer is an uncommon but highly lethal disease. Surgical resection is the gold standard of treatment for early-stage disease. Traditional surgical approach entailed significant convalescence, hospital stay, and morbidity and mortality. Transhiatal esophagectomy (THE) involves blind dissection of the esophagus with minimal mediastinal lymphadenectomy. Integration of robotic surgery is an alternate platform for minimally invasive approach while maintaining safety and following oncologic principles. We review our technique for minimally invasive THE using robotic technology, demonstrating the safety and efficacy of robotic technology surgery. We present a retrospective review of a single surgeon's data of patients treated with robotic-assisted THE, with a chart review to evaluate pathology, adequacy of surgical resection, nodal harvest, and perioperative course. Robotic THE (rTHE) shows promise as a valid option for esophageal resection, including premalignant and advanced stages of cancer. Adequate transhiatal mediastinal nodal resection can be performed with the robot.

Robot-Assisted Mckeown Esophagectomy is Feasible After Neoadjuvant Chemoradiation. Our Initial Experience

Neoadjuvant chemoradiation has become the standard of care for esophageal cancer, especially for middle third esophageal lesions and those with squamous histology. Although more and more thoracic surgeons and surgical oncologists have now shifted to video-assisted and robot-assisted thoracoscopic esophagectomy; there is still limited experience for the use of minimal-assisted approaches in patients undergoing surgery after neoadjuvant chemoradiation. Most surgeons have concerns of feasibility, safety, and oncological outcomes as well as issues related to difficult learning curve in adopting robotic esophagectomy in patients after chemoradiation. We present our initial experience of Robot-Assisted Mckeown Esophagectomy in 27 patients after neoadjuvant chemoradiation, from May 2013 to October 2014. All patients underwent neoadjuvant chemoradiation to a dose of 50.4 Gy/25Fr with concurrent weekly cisplatin, followed by reassessment with clinical examination and repeat FDG PET/CT 6 weeks after completion of chemoradiation. Patients with progressive disease underwent palliative chemotherapy while patients with either partial or significant response to chemoradiation underwent Robot-Assisted Mckeown Esophagectomy with esophageal replacement by gastric conduit and esophagogastric anastomosis in the left neck. Out of 27 patients, 92.5 % patients had stage cT3/T4 tumours and node-positive disease in 48.1 % on imaging. Most patients were middle thoracic esophageal cancers (23/27), with squamous histology in all except for one. All patients received neoadjuvant chemoradiation and subsequently underwent Robot Assisted Mckeown Esophagectomy. The average time for robot docking, thoracic mobilization and total surgical procedure was 13.2, 108.4 and 342.7 min, respectively. The procedure was well tolerated by all patients with only one case of peri-operative mortality. Average ICU stay was 6.35 days (range 3-9 days). R0 resection rate of 96.3 % and average lymph node yield of 18 could be achieved. Pathological node negativity rate (pN0) and complete response (pCR) were 66.6 and 44.4 %, respectively. In the initial cases, four patients had to be converted to open due technical reasons or intraoperative complications. The present study, with shorter operative times, similar ICU stay, overall low morbidity, and mortality and optimal oncological outcomes suggest that robot-assisted thoracic mobilization of esophagus in patients with prior chemoradiation is feasible and safe with acceptable oncological outcomes. It has a shorter learning curve and hence allows for a transthoracic minimally invasive transthoracic esophagectomy to more and more patients, otherwise unfit for conventional approach.

Short-term outcomes of robotic radical esophagectomy for esophageal cancer by a nontransthoracic approach compared with conventional transthoracic surgery

Transthoracic esophagectomy (TTE) is believed to have advantages for mediastinal lymphadenectomy in the treatment of resectable esophageal cancer despite its association with a greater incidence of pulmonary complications and postoperative mortality. Transhiatal esophagectomy is regarded as less invasive, though insufficient in terms of lymph node dissection. With the aim of achieving lymph dissection equivalent to that of TTE, we have developed a nontransthoracic esophagectomy (NTTE) procedure combining a video-assisted cervical approach for the upper mediastinum and a robot-assisted transhiatal approach for the middle and lower mediastinum. We prospectively studied 22 accumulated cases of NTTE and verified feasibility by analyzing perioperative and histopathological outcomes. We compared this group's short-term outcomes with outcomes of 139 equivalent esophageal cancer cases operated on at our institution by conventional TTE (TTE group). In the NTTE group, there were no procedure-related events and no midway conversions to the conventional surgery; the mean operation time was longer (median, 524 vs. 428 minutes); estimated blood loss did not differ significantly between the two groups (median, 385 mL vs. 490 mL); in the NTTE group, the postoperative hospital stay was shorter (median, 18 days vs. 24 days). No postoperative pneumonia occurred in the NTTE group. The frequencies of other major postoperative complications did not differ significantly, nor were there differences in the numbers of harvested mediastinal lymph nodes (median, 30 vs. 29) or in other histopathology findings. NTTE offers a new radical procedure for resection of esophageal cancer combining a cervical video-assisted approach and a transhiatal robotic approach. Although further accumulation of surgical cases is needed to corroborate these results, NTTE promises better prevention of pulmonary complications in the management of esophageal cancer.

Minimally invasive surgery for upper gastrointestinal cancer: Our experience and review of the literature

Minimally invasive surgery (MIS) for upper gastrointestinal (GI) cancer, characterized by minimal access, has been increasingly performed worldwide. It not only results in better cosmetic outcomes, but also reduces intraoperative blood loss and postoperative pain, leading to faster recovery; however, endoscopically enhanced anatomy and improved hemostasis via positive intracorporeal pressure generated by CO2 insufflation have not contributed to reduction in early postoperative complications or improvement in long-term outcomes. Since 1995, we have been actively using MIS for operable patients with resectable upper GI cancer and have developed stable and robust methodology in conducting totally laparoscopic gastrectomy for advanced gastric cancer and prone thoracoscopic esophagectomy for esophageal cancer using novel technology including da Vinci Surgical System (DVSS). We have recently demonstrated that use of DVSS might reduce postoperative local complications including pancreatic fistula after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. In this article, we present the current status and future perspectives on MIS for gastric and esophageal cancer based on our experience and a review of the literature.

Robot-assisted thoracoscopic esophagectomy with extensive mediastinal lymphadenectomy: experience with 114 consecutive patients with intrathoracic esophageal cancer

The study aims to report the operative outcomes of robot-assisted thoracoscopic esophagectomy (RATE) with extensive mediastinal lymphadenectomy (ML) for intrathoracic esophageal cancer. We analyzed a prospective database of 114 consecutive patients who underwent RATE with lymph node dissection along recurrent laryngeal nerve (RLN) followed by cervical esophagogastrostomy. The study included 104 men with a mean age of 63.1 ± 0.8 years. Of these, 110 (96.5%) had squamous cell carcinoma, and the location of the tumor was upper esophagus in 7 (6.1%), middle in 62 (54.4%), and lower in 45 (39.5%). Preoperative concurrent chemoradiation was performed in 15 patients (13.2%). All but one patient underwent successful RATE, and R0 resection was achieved in 111 patients (97.4%). Extended ML and total ML were performed in 24 (21.1%) and 90 (78.9%) patients, respectively. Total operation time was 419.6 ± 7.9 minutes, and robot console time was 206.6 ± 5.2 minutes. The mean number of total, mediastinal, and RLN nodes was 43.5 ± 1.4, 24.5 ± 1.0, and 9.7 ± 0.7, respectively. The most common complication was RLN palsy (30, 26.3%), followed by anastomotic leakage (17, 14.9%) and pulmonary complications (11, 9.6%). Median hospital stay was 16 days, and 90-day mortality was observed in three patients (2.5%). On multivariate analysis, preoperative concurrent chemoradiation was a risk factor for pulmonary complications (odds ratio 7.42, 95% confidence interval 1.91-28.8, P = 0.004). RATE with extensive ML could be performed safely with acceptable postoperative outcomes. Long-term survival data should be followed in the future to verify the oncological outcome of the procedure.

Perioperative outcomes associated with robotic Ivor Lewis esophagectomy in patient's undergoing neoadjuvant chemoradiotherapy

BACKGROUND

Neoadjuvant chemoradiotherapy (NCR) for the treatment of esophageal cancer has been associated with increased perioperative morbidity and mortality. Minimally invasive procedures utilizing robotic techniques have been shown to reduce perioperative complications and length of hospitalization (LOH). The purpose of this study is to compare perioperative outcomes between patients undergoing NCR and robotic-assisted Ivor Lewis esophagectomy (RAIL) versus upfront RAIL.

METHODS

A database of esophagectomy patients was queried to identify RAIL patients. Differences in perioperative outcomes were analyzed between NCR and non NCR patients.

RESULTS

Eighty-nine patients were identified who underwent RAIL Seventy-seven patients (87%) had NCR and 22 patients did not (13%). The median age was 66 (range, 44-83). The median age of the patients treated with NCR was younger {69 [44-83] vs. 64 [46-81] years respectively, P=0.05}. The patients who underwent NCR had a higher BMI then those who went straight to esophagectomy (31 vs. 27; P=0.001). There were no conversions to open laparotomy or thoracotomy in either group. There were no statistically significant differences in the mean operative times and estimated blood loss (EBL) between both groups. Complications occurred in 17 (19.1%) patients. There were no statistically significant differences in the rates of any complications between patients receiving NCR and those that did not receive NCR (P=0.11). There were no deaths in either group. The total number of days in hospital and total number of intensive care unit (ICU) days were also similar in both groups (P=0.25). There was no statistically significant difference in the mean number of lymph nodes harvested in the patients treated with NCR compared with those treated without NCR.

CONCLUSIONS

We have demonstrated that RAIL is a safe and feasible option for patients with esophageal cancer. The administration of NCR to RAIL did not result in an increase in perioperative morbidity and mortality. The number of lymph nodes harvested and the completeness of resection was also similar between patients who received NCR and those who did not. Longer follow-up is required in order to determine long term oncologic outcome.

Robotic-Assisted Paraesophageal Hernia Repair: Initial Experience at a Single Institution

BACKGROUND

Laparoscopic surgery is considered the standard approach for the treatment of paraesophageal hernias (PEHs). Despite its advantages, this approach is technically demanding with a significant learning curve. Data about the safety and utility of the robotically assisted paraesophageal hernia repair (RA-PEHR) are scarce. The aim of this study is to assess the feasibility and safety of robotic assistance for the treatment of PEH.

MATERIALS AND METHODS

Between June 2010 and December 2015, patients who underwent elective RA-PEHR were included in a prospectively collected database. Demographic data, American Society of Anesthesiologists (ASA) classification, preoperative testing, operative time (OT), length of hospital stay (LOS), conversion rate, morbidity, and mortality were recorded and reviewed retrospectively.

RESULTS

Sixty-one patients underwent RA-PEHR with mesh, 72% were female (mean age of 63 and mean body mass index [BMI] of 30). ASA classification was 2.6 (57% of patients had an ASA III). With respect to the type of the hernia, the preoperative diagnosis was: Type II 26%, III 64%, and IV 13%. OT averaged 186 minutes (88-360), including robot setup time. After the 16th case, OT significantly decreased by 4.09 minutes (P = .01). There were no conversions. The average blood loss was 51 mL. Perioperative complications, including intraoperative and 30-day complications, were 6% and 23%, respectively. The mean length of hospitalization was 2.6 (1-18) days. There were no deaths. Forty patients (66%) were available for follow-up, and length of follow-up was 17 ± 15 months. Anatomic recurrence was observed in 42% of patients and only 23% of patients were symptomatic.

CONCLUSIONS

This report represents the largest series to date of RA-PEHR. RA-PEHR has proved to be feasible and safe with a learning curve comparable to the standard laparoscopic approach.

Robot-assisted minimally invasive esophagectomy for esophageal cancer: A systematic review

This paper describes the technique of robot-assisted minimally invasive esophagectomy. (RAMIE) Also, a systematic literature search was performed. Safety and feasibility of RAMIE was demonstrated in all reports. Short term oncologic results show radical resection rates of 77-100% and 18-43 lymph nodes harvested. RAMIE offers great visualization of the mediastinum and enables meticulous dissection in the mediastinum from diaphragm to thoracic inlet.

Robot-Assisted Minimally Invasive Ivor Lewis Esophagectomy With Real-Time Perfusion Assessment

BACKGROUND

Surgical resection is viewed as the most effective way to ensure both locoregional control and long-term survival in esophageal cancer. Although minimally invasive esophagectomy has been widely accepted as an alternative to open surgery, the role of robotic assistance has yet to be elucidated. We report our institutional experience with robotic-assisted Ivor Lewis esophagectomy using real-time perfusion assessment and demonstrate this as a safe and technically feasible alternative to traditional open Ivor Lewis esophagectomy.

METHODS

A retrospective chart review of all patients undergoing robotic-assisted Ivor Lewis esophagectomy at a single institution from 2011 to 2014 was performed. Operative and postoperative outcomes were recorded.

RESULTS

Fifty-four patients underwent robotic-assisted Ivor Lewis esophagectomy during the study period. Indication for surgery was cancer in 49 patients, 38 of whom underwent neoadjuvant chemoradiation therapy. The average operative time was 6 hours 2 minutes, and the average blood loss was 74 mL. There was 1 postoperative mortality (1.9%). Three (5.5%) patients experienced an anastomotic leak. The average number of lymph nodes harvested in cancer patients was 16.2 (range, 3 to 35). The average length of stay was 12.9 days.

CONCLUSIONS

Our study demonstrates that robotic-assisted Ivor Lewis esophagectomy using real-time perfusion assessment is a safe and technically feasible alternative to traditional open Ivor Lewis esophagectomy. It allows for R0 resection with adequate lymph node harvesting and a short hospital stay.

Robotic transthoracic esophagectomy

BACKGROUND

We have initially published our experience with the robotic transthoracic esophagectomy in 32 patients from a single institute. The present paper is the extension of our experience with robotic system and to best of our knowledge this represents the largest series of robotic transthoracic esophagectomy worldwide. The objective of this study was to investigate the feasibility of the robotic transthoracic esophagectomy for esophageal cancer in a series of patients from a single institute.

METHODS

A retrospective review of medical records was conducted for 83 esophageal cancer patients who underwent robotic esophagectomy at our institute from December 2009 to December 2012. All patients underwent a thorough clinical examination and pre-operative investigations. All patients underwent robotic esophageal mobilization. En-bloc dissection with lymphadenectomy was performed in all cases with preservation of Azygous vein. Relevant data were gathered from medical records.

RESULTS

The study population comprised of 50 men and 33 women with mean age of 59.18 years. The mean operative time was 204.94 mins (range 180 to 300). The mean blood loss was 86.75 ml (range 50 to 200). The mean number of lymph node yield was 18. 36 (range 13 to 24). None of the patient required conversion. The mean ICU stay and hospital stay was 1 day (range 1 to 3) and 10.37 days (range 10 to 13), respectively. A total of 16 (19.28%) complication were reported in these patents. Commonly reported complication included dysphagia, pleural effusion and anastomotic leak. No treatment related mortality was observed. After a median follow-up period of 10 months, 66 patients (79.52%) survived with disease free stage.

CONCLUSIONS

We found robot-assisted thoracoscopic esophagectomy feasible in cases of esophageal cancer. The procedure allowed precise en-bloc dissection with lymphadenectomy in mediastinum with reduced operative time, blood loss and complications.

[Initial results of robotic esophagectomy for esophageal cancer]

INTRODUCTION

There is scant experience with robot-assisted esophagectomy in cases of esophageal and gastro-esophageal junction cancer. Our aim is to report our current experience.

PATIENTS AND METHODS

Observational cohort study of the first 32 patients who underwent minimally invasive esophagectomy for esophageal cancer from September 2011 to June 2014. The gastric tube was created laparoscopically. In the thoracic field, a robot-assisted thoracoscopic approach was performed in the prone position with intrathoracic robotic hand-sewn anastomosis. Patient and tumour characteristics, surgical technique, short-term outcomes (morbidity and mortality) and oncological results (radicality and number of removed nodes) were evaluated.

RESULTS

Thirty-two patients, with a mean age of 58 years (34-74) were treated by a totally minimally invasive esophagectomy: robotic laparoscopy and thoracoscopy (11 McKeown and 21 Ivor-Lewis). Twenty-nine received neoadjuvant chemoradiotherapy. There were no conversions to open surgery. Console time was 218minutes (190-285). Blood loss was 170ml (40-255). One patient died from cardiac disease. Nine patients had a major complication (Dindo-Clavien grade II or higher). There was no case of respiratory complication or recurrent laryngeal nerve palsy. Five patients had intrathoracic fistula, 4 radiological and one clinical. Three had chylothorax, 2 cervical fistula and one gastric tube necrosis. The median hospital stay was 12 days (8-50). All the resections were R0 and the median of removed lymph nodes was 16 (2-23).

CONCLUSIONS

Our results suggest that minimally invasive esophagectomy with robot-assisted thoracoscopy is safe and achieves oncological standards.

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

Thoracoscopic versus robotic approaches: advantages and disadvantages

The overall advantages of thoracoscopy over thoracotomy in terms of patient recovery have been fairly well established. The use of robotics, however, is a newer and less proven modality in the realm of thoracic surgery. Robotics offers distinct advantages and disadvantages in comparison with video-assisted thoracoscopic surgery. Robotic technology is now used for a variety of complex cardiac, urologic, and gynecologic procedures including mitral valve repair and microsurgical treatment of male infertility. This article addresses the potential benefits and limitations of using the robotic platform for the performance of a variety of thoracic operations.

Robot-assisted gastrectomy and oesophagectomy for cancer

BACKGROUND

Robot-assisted surgery is a technically feasible alternative to open and laparoscopic surgery, which is being more frequently used in general surgery. We undertook this review to investigate whether robotic assistance provides a significant benefit for oesophagogastric cancer surgery.

METHODS

Electronic databases were searched for original English-language publications for robotic-assisted gastrectomy and oesophagectomy between January 1990 and October 2013.

RESULTS

Sixty-one publications were included. Thirty-five included gastrectomy, 31 included oesophagectomy and five included both operations. Several publications suggest that robot-assisted subtotal gastrectomy can be as safe and effective as an open or laparoscopic procedure, with equal outcomes with regard to the number of lymph nodes resected, overall morbidity and perioperative mortality, and length of hospital stay. Robotic assistance is associated with longer operation times but also with less blood loss in some reports. A significant benefit for robotic assistance has not been shown for the more extensive operations of oesophagectomy or total gastrectomy with D2-lymphadenectomy. There are very few oncologic data regarding local recurrence or long-term survival for any of the robotic operations.

CONCLUSIONS

No significant differences in morbidity, mortality or number of lymph node harvested have been shown between robot-assisted and laparoscopic gastrectomy or oesophagectomy. Robotic surgery, with its relatively short learning curve, may facilitate reproducible minimally invasive surgery in this field but operation times are reportedly longer and cost differences remain unclear. Randomized trials with oncologic outcomes and cost comparisons are needed.

Outcomes of robotic-assisted transhiatal esophagectomy for esophageal cancer after neoadjuvant chemoradiation

BACKGROUND

We previously reported our experience performing robotic-assisted transhiatal esophagectomy (RATE) in patients with early-stage esophageal cancer who had had no preoperative treatment. The purpose of this report was to determine if RATE could be performed safely with good outcomes for esophageal cancer in a more recent series of patients, the majority of whom were treated with neoadjuvant chemoradiation.

SUBJECTS AND METHODS

This was a retrospective review of patients with adenocarcinoma of the distal esophagus or gastroesophageal junction who underwent RATE between November 2006 and November 2012 at a single tertiary-care hospital. Main outcome measures included operative and oncologic parameters, morbidity, and mortality.

RESULTS

In total, 23 patients underwent RATE, consisting of 20 men and 3 women with a median age of 64 years (range, 40-81 years). The majority of patients (19/23 [83%]) underwent neoadjuvant chemoradiation, although 1 patient had preoperative chemotherapy only, and 3 patients went straight to surgery. Median operative time was 231 minutes (range, 179-319 minutes), and median estimated blood loss was 100 mL (range, 25-400 mL). There were no conversions to open surgery. Complications included seven strictures, two anastomotic leaks, and two pericardial/pleural effusions requiring drainage. One patient required pyloroplasty 3 months after esophagectomy. One patient died from pulmonary failure 21 days after surgery (30-day mortality rate of 4%). The median length of stay was 9 days (range, 7-37 days). Seven of the 19 patients who underwent preoperative chemoradiation had a complete response on final pathology. The mean lymph node yield was 15 (range, 5-29), and surgical margins were negative for cancer in 21 cases.

CONCLUSIONS

RATE can be performed safely with good oncologic outcomes following neoadjuvant chemoradiation in patients with esophageal cancer. This technique has become our choice of operation for most patients with esophageal cancer.

Minimally invasive surgery for esophageal cancer: review of the literature and institutional experience

BACKGROUND

Esophageal cancer represents a major public health problem in the world. Several minimally invasive esophagectomy (MIE) techniques have been described and represent a safe alternative for the surgical management of esophageal cancer in selected centers with high volume and surgeons experienced in minimally invasive procedures.

METHODS

The authors reviewed the most recent and largest studies published in the medical literature that reported the outcomes for MIE techniques.

RESULTS

In larger series, MIE has proven to be equivalent in postoperative morbidity and mortality to the open esophagectomy. However, MIE has been associated with less blood loss, reduced postoperative pain, decreased time in the intensive care unit, and shortened length of hospital stay compared with the conventional open approaches. Despite limited data, no significant difference in survival stage for stage has been observed between open esophagectomy and MIE.

CONCLUSIONS

The myriad of MIE techniques complicates the debate for defining the optimal surgical approach for the treatment of esophageal cancer. Randomized controlled trials comparing MIE with conventional open esophagectomy are needed to clarify the ideal procedure with the lowest postoperative morbidity, best quality of life after surgery, and long-term survival.

Robot-assisted gastroesophageal surgery: usefulness and limitations

Robot-assisted surgery overcomes some of the limitations of traditional laparoscopic surgery. We present our experience and lessons learned in two surgical units dedicated to gastro-esophageal surgery. From June 2009 to January 2013, we performed 130 robot-assisted gastroesophageal procedures, including Nissen fundoplication (29), paraesophageal hernia repair (18), redo for failed antireflux surgery (11), esophagectomy (19), subtotal (5) or wedge (4) gastrectomy, Heller myotomy for achalasia (22), gastric bypass for morbid obesity (12), thoracoscopic leiomyomectomy (4), Morgagni hernia repair (3), lower-third esophageal diverticulectomy (1) and two diagnostic procedures. There were 80 men and 50 women with a median age of 54 years (interquartile range: 46-65). Ten patients (7.7 %) had severe postoperative complications: eight after esophagectomy (three leaks-two cervical and one thoracic-managed conservatively), one stapler failure, one chylothorax, one case of gastric migration to the thorax, one case of biliary peritonitis, and one patient with a transient ventricular dyskinesia. One redo procedure needed reoperation because of port-site bleeding, and one patient died of pulmonary complications after a giant paraesophageal hernia repair; 30-day mortality was, therefore, 0.8 %. There were six elective and one forced conversions (hemorrhage), so total conversion was 5.4 %. Median length of stay was 4 days (IQ range 3-7). Robot-assisted gastroesophageal surgery is feasible and safe, and may be applied to most common procedures. It seems of particular value for Heller myotomy, large paraesophageal hernias, redo antireflux surgery, transhiatal dissection, and hand-sewn intrathoracic anastomosis.

Defining the learning curve for robotic-assisted esophagogastrectomy

INTRODUCTION

The expansion of robotic-assisted surgery is occurring quickly, though little is generally known about the "learning curve" for the technology with utilization for complex esophageal procedures. The purpose of this study is to define the learning curve for robotic-assisted esophagogastrectomy with respect to operative time, conversion rates, and patient safety.

METHODS

We have prospectively followed all patients undergoing robotic-assisted esophagogastrectomy and compared operations performed at our institutions by a single surgeon in successive cohorts of 10 patients. Our measures of proficiency included: operative times, conversion rates, and complications. Statistical analyses were undertaken utilizing Spearman regression analysis and Mann-Whitney U test. Significance was accepted with 95 % confidence.

RESULTS

Fifty-two patients (41 male: 11 female) of mean age 66.2 ± 8.8 years underwent robotic-assisted esophagogastrectomies for malignant esophageal disease. Neoadjuvant chemoradiation was administered to 30 (61 %) patients. A significant reduction in operative times (p <0.005) following completion of 20 procedures was identified (514 ± 106 vs. 397 ± 71.9). No conversions to open thoracotomy were required. Complication rates were low and not significantly different between any 10-patient cohort; however, no complications occurred in the final 10-patient cohort. There were no in-hospital mortalities.

CONCLUSIONS

For surgeons proficient in performing minimally-invasive esophagogastrectomies, the learning curve for a robotic-assisted procedure appears to begin near proficiency after 20 cases. Operative complications and conversions were infrequent and unchanged across successive 10-patient cohorts.

Recent developments in esophageal adenocarcinoma

Answer questions and earn CME/CNE Esophageal adenocarcinoma (EAC) is characterized by 6 striking features: increasing incidence, male predominance, lack of preventive measures, opportunities for early detection, demanding surgical therapy and care, and poor prognosis. Reasons for its rapidly increasing incidence include the rising prevalence of gastroesophageal reflux and obesity, combined with the decreasing prevalence of Helicobacter pylori infection. The strong male predominance remains unexplained, but hormonal influence might play an important role. Future prevention might include the treatment of reflux or obesity or chemoprevention with nonsteroidal antiinflammatory drugs or statins, but no evidence-based preventive measures are currently available. Likely future developments include endoscopic screening of better defined high-risk groups for EAC. Individuals with Barrett esophagus might benefit from surveillance, at least those with dysplasia, but screening and surveillance strategies need careful evaluation to be feasible and cost-effective. The surgery for EAC is more extensive than virtually any other standard procedure, and postoperative survival, health-related quality of life, and nutrition need to be improved (eg, by improved treatment, better decision-making, and more individually tailored follow-up). Promising clinical developments include increased survival after preoperative chemoradiotherapy, the potentially reduced impact on health-related quality of life after minimally invasive surgery, and the new endoscopic therapies for dysplastic Barrett esophagus or early EAC. The overall survival rates are improving slightly, but poor prognosis remains a challenge.

Management of abdominal malignancies: updates from the International Association of Surgeons, Gastroenterologists and Oncologists

The 22nd World Congress of the International Association of Surgeons, Gastroenterologists and Oncologists was held from 5-8 December 2012 in Bangkok, Thailand. Themed 'Challenges and Controversies in the Management of Abdominal Diseases: Current Possibility and Future Expectation', the congress featured ten main topics including: upper GI tract surgery, lower GI tract surgery, hepatic surgery, biliary tract surgery, pancreatic surgery, interventional chemo-immuno-radiotherapy, laparoscopic endoscopic surgery, multidisciplinary approaches, innovation and advanced technology and robotic surgery. Approximately 200 guest speakers were invited to share their experiences and expertise, while 600 abstracts were submitted for oral and poster presentations. In this article, the authors highlight and summarize some of the presentations from this conference.

Initial experience from a large referral center with robotic-assisted Ivor Lewis esophagogastrectomy for oncologic purposes

BACKGROUND

We report our initial experience of patients undergoing robotic-assisted Ivor Lewis esophagogastrectomy (RAIL) for oncologic purposes at a large-referral center.

METHODS

A retrospective review of all consecutive patients undergoing RAIL from 2010-2011 was performed. Basic demographics were recorded. Oncologic variables recorded included: tumor type, location, postoperative tumor margins, and nodal harvest. Immediate 30-day postoperative complications also were analyzed.

RESULTS

Fifty patients underwent RAIL with median age of 66 (range 42-82) years. The mean body mass index was 28.6 ± 0.7 kg/m(2); 54% and the majority had an American Society of Anesthesiologists classification of 3. The mean and median number of lymph nodes retrieved during surgery was 20 ± 1.4 and 18.5 respectively. R0 resections were achieved in all patients. Postoperative complications occurred in 14 (28%) patients, including atrial fibrillation in 5 (10%), pneumonia in 5 (10%), anastomotic leak in 1 (2%), conduit staple line leak in 1 (2%), and chyle leak in 2 (4%). The median ICU stay and length of hospitalization (LOH) were 2 and 9 days respectively. Total mean operating time calculated from time of skin incision to wound closure was 445 ± 85 minutes; however, operative times decreased over time. Similarly, there was a trend toward lower complications after the first 29 cases but this did not reach statistical significance. There were no in-hospital mortalities.

CONCLUSIONS

We demonstrated that RAIL for esophageal cancer can be performed safely and may be associated with fewer complications after a learning curve, shorter ICU stay, and LOH.

Oesophageal cancer--an overview

Oesophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Diagnosis and accuracy of pretreatment staging have substantially improved throughout the past three decades. Therapy is challenging and the optimal approach is still debated. Oesophagectomy is considered to be the procedure of choice in patients with operable oesophageal cancer. Endoscopic measures and limited surgical procedures provide an alternative in patients with early carcinomas confined to the oesophageal mucosa. Chemotherapy and radiotherapy or concurrent chemoradiotherapy are also frequently applied, either as definitive treatment or as neoadjuvant therapy within multimodal approaches. The question of whether multimodal treatment offers improved results has been the focus of many studies since the 1990s. Although results are discordant and even some meta-analyses remain inconclusive, it is now widely accepted that multimodal therapy leads to a modest survival benefit. The role of minimally invasive oesophagectomy is not yet defined. Endoscopic stent insertion, radiotherapy and other palliative measures provide relief of tumour-related symptoms in advanced, unresectable tumour stages.