Quality of life after robot-assisted transmediastinal radical surgery for esophageal cancer

Survival outcomes of robot-assisted transmediastinal esophagectomy in patients with esophageal squamous cell carcinoma

We developed a robot-assisted transmediastinal esophagectomy (RATME) to reduce the surgical invasiveness of open transthoracic esophagectomy (oTTE). However, the long-term survival outcomes of patients who undergo RATME remain unclear. Patients who underwent RATME for esophageal squamous cell carcinoma (ESCC) between January 2012 and April 2020 were enrolled. Overall survival (OS), relapse-free survival (RFS), and ESCC cause-specific survival (CSS) were analyzed according to clinical stage. Survivals were compared between patients who underwent the RATME and oTTE using propensity score matching analysis. One hundred and twenty-seven patients who underwent RATME were included in the analysis. The 3- and 5-year OS rates were 96.2 and 92.1% for cStage I RATME group, 84.8 and 82.3% for cStage II, and 61.8 and 61.8% for cStage III, respectively. The 3- and 5-year RFS rates were 94.3 and 84.3% for cStageI, 71.7 and 69.3% for cStage II, and 5 48.2 and 48.2% for cStage III, respectively. Survival analysis using 74 paired patients showed that the RATME group had better OS and RFS than the oTTE group (p = 0.0028 and p = 0.016, respectively), but equivalent CSS (p = 0.078). The OS of the RATME group stratified by clinical stage was equivalent to that of the comprehensive registry data from Japan, and showed better OS and RFS than the oTTE group, indicating that RATME radicality is guaranteed with regard to long-term survival.

Analysis of factors associated with operative difficulty in thoracoscopic esophageal cancer surgery in the left-decubitus position: a single-center retrospective study

BACKGROUND

The degree of difficulty in the overall procedure and forceps handling encountered by surgeons is greatly influenced by the positional relationship of intrathoracic organs in minimally invasive esophagectomy. This study aimed to identify the anatomical factors associated with the difficulty of minimally invasive esophagectomy assessed by intraoperative injuries and postoperative outcomes.

METHODS

Minimally invasive esophagectomy in the left-decubitus position was performed in 258 patients. We defined α (mm) as the anteroposterior distance between the front of the vertebral body and aorta, β (mm) as the distance between the center of the vertebral body and center of the aorta, and γ (degree) as the angle formed at surgeon's right-hand port site by insertion of lines from the front of aorta and from the front of vertebrae in the computed tomography slice at the operator's right-hand forceps hole level. We retrospectively analyzed the correlations among clinico-anatomical factors, surgeon- or assistant-caused intraoperative organ injuries, and postoperative complications.

RESULTS

Intraoperative injuries significantly correlated with shorter α (0.2 vs. 3.9), longer β (33.0 vs. 30.5), smaller γ (3.0 vs. 4.3), R1 resection (18.5% vs. 8.3%), and the presence of intrathoracic adhesion (46% vs. 26%) compared with the non-injured group. Division of the median values into two groups showed that shorter α and smaller γ were significantly associated with organ injury. Longer β was significantly associated with postoperative tachycardia onset, respiratory complications, and mediastinal recurrence. Furthermore, the occurrence of intraoperative injuries was significantly associated with the onset of postoperative pulmonary complications.

CONCLUSIONS

Intrathoracic anatomical features greatly affected the procedural difficulty of minimally invasive esophagectomy, suggesting that preoperative computed tomography simulation and appropriate port settings may improve surgical outcomes.

Clinical advantage of transmediastinal esophagectomy in terms of postoperative respiratory complications

BACKGROUND

Although the transmediastinal approach as a radical esophagectomy for esophageal carcinoma patients has attracted attention, its advantages over the transthoracic approach remain unclear. This study aimed to evaluate the efficacy of transmediastinal esophagectomy (TME) in terms of postoperative respiratory complications compared to that of open transthoracic esophagectomy (TTE).

METHODS

We reviewed patients with thoracic and abdominal esophageal carcinoma who underwent TME or TTE between February 2014 and November 2021. We compared postoperative respiratory complications as the primary outcome. The secondary outcomes included perioperative operation time, blood loss, postoperative complications, and the number of harvested mediastinal lymph nodes.

RESULTS

Overall, 60 and 54 patients underwent TME and TTE, respectively. The baseline characteristics were similar between the two groups, except for age and histological type. There were no intraoperative lethal complications in either group. The incidence of respiratory complications was significantly lower in the TME group than in the TTE group (6.7 vs. 22.2%, p = 0.03). The TME group had a shorter operation time (403 vs. 451 min, p < 0.01), less blood loss (107 vs. 253 mL, p < 0.01), and slightly higher anastomotic leakage (11.7 vs. 5.6%, p = 0.33). The number of harvested lymph nodes was similar in both groups (24 vs. 26, p = 0.10). Multivariate analysis revealed that TME is an independent factor in reducing respiratory complications (odds ratio = 0.27, p = 0.04).

CONCLUSIONS

TME for esophageal carcinoma was performed safely. TME was superior to TTE in terms of postoperative respiratory complications; however, the relatively higher frequency of anastomotic leakage should be considered and requires further evaluation.

Clinical-pathological features and perioperative outcomes of mediastinoscopy vs. thoracoscopy esophagectomy in esophageal cancer: A meta-analysis

Objective

To compare the clinicopathological features and perioperative outcomes of video-assisted mediastinoscopy esophagectomy (VAME) compared to video-assisted thoracoscopy esophagectomy (VATE) in esophageal cancer.

Methods

We comprehensively searched online databases (PubMed, Embase, Web of Science and Wiley online library) to find available studies exploring the clinicopathological features and perioperative outcomes between VAME and VATE in esophageal cancer. Relative risk (RR) with 95% confidence interval (CI) and standardized mean difference (SMD) with 95% CI were used to evaluate the perioperative outcomes and clinicopathological features.

Results

A total of seven observational studies and one randomized controlled trial involving 733 patients were considered eligible for this meta-analysis, of which 350 patients underwent VAME in contrast to 383 patients underwent VATE. Patients in the VAME group had more pulmonary comorbidities (RR = 2.18, 95% CI 1.37-3.46, P = 0.001). The pooled results showed that VAME shortened the operation time (SMD = -1.53, 95% CI -2.308--0.76, P = 0.000), and retrieved less total lymph nodes (SMD = -0.70, 95% CI -0.90--0.50, P = 0.000). No differences were observed in other clinicopathological features, postoperative complications or mortality.

Conclusions

This meta-analysis revealed that patients in the VAME group had more pulmonary disease before surgery. The VAME approach significantly shortened the operation time and retrieved less total lymph nodes and did not increase intra- or postoperative complications.

Transthoracic Esophagectomy: Hand-sewn Versus Side-to-side Linear-stapled Versus Circular-stapled Anastomosis: A Systematic Review and Meta-analysis

BACKGROUND

Three anastomotic techniques are mostly used to create an esophagogastric anastomosis in a transthoracic esophagectomy: hand-sewn (HS), side-to-side linear-stapled (SSLS), and circular-stapled (CS). The aim of this study was to compare surgical outcomes after HS, SSLS, and CS intrathoracic esophagogastric anastomosis.

MATERIALS AND METHODS

A systematic review using the MEDLINE database was performed to identify original articles analyzing outcomes after HS, SSLS, and CS esophagogastric anastomosis. The main outcome was an anastomotic leakage rate. Secondary outcomes included overall morbidity, major morbidity, and mortality. A meta-analysis of proportions and linear regression models were used to assess the effect of each anastomotic technique on the different outcomes.

RESULTS

A total of 101 studies comprising 12,595 patients were included; 8835 (70.1%) with CS, 2532 (20.1%) with HS, and 1228 (9.8%) with SSLS anastomosis. Anastomotic leak occurred in 10% [95% confidence interval (CI), 6%-15%], 9% (95% CI, 6%-13%), and 6% (95% CI, 5%-7%) of patients after HS, SSLS, and CS anastomosis, respectively. Risk of anastomotic leakage was significantly higher with HS anastomosis (odds ratio=1.73, 95% CI: 1.47-2.03, P<0.0001) and SSLS (odds ratio=1.68, 95% CI: 1.36-2.08, P<0.0001), as compared with CS. Overall morbidity (HS: 52% vs. SLSS: 39% vs. CS: 35%) and major morbidity (HS: 33% vs. CS: 19%) rates were significantly lower with CS anastomosis. Mortality rate was 4% (95% CI, 3%-6%), 2% (95% CI, 2%-3%), and 3% (95% CI, 3%-4%) after HS, SSLS, and CS anastomosis, respectively.

CONCLUSION

HS and SSLS intrathoracic esophagogastric anastomoses are associated with significantly higher rates of an anastomotic leak than CS anastomosis.

Outcomes of robotic esophagectomy

Esophagectomy has long been considered the standard of care for early-stage (≤ T2N0) esophageal cancer. Minimally invasive esophagectomy (MIE), using a combined laparoscopic and thoracoscopic approach, was first performed in the 1990s and showed significant improvements over open approaches. Refinement of MIE arrived in the form of robotic-assisted minimally invasive esophagectomy (RAMIE) in 2004. MIE is a challenging procedure for which consensus on optimal technique is still elusive. Although nonrobotic MIE confers significant advantages over open approaches, MIE remains associated with stubbornly high rates of complications, including pneumonia, aspiration, arrhythmia, anastomotic leakage, surgical site infection, and vocal cord palsy. RAMIE was envisioned to improve operative-associated morbidity while achieving equivalent or superior oncologic outcomes to nonrobotic MIE. However, owing to RAMIE’s significant upfront costs, steep learning curve, and other requirements, adoption remains less than widespread and convincing evidence supporting its use from well-designed studies is lacking. In this review, we compare operative, oncologic, and quality-of-life outcomes between open esophagectomy, nonrobotic MIE, and RAMIE. Although RAMIE remains a relatively new and underexplored modality, several studies in the literature show that it is feasible and results in similar outcomes to other MIE approaches. Moreover, RAMIE has been associated with favorable patient satisfaction and quality of life.

Comparison of short-term outcomes between transthoracic and robot-assisted transmediastinal radical surgery for esophageal cancer: a prospective study

Background

The present study aimed to assess the lower invasiveness of robot-assisted transmediastinal radical esophagectomy by prospectively comparing this procedure with transthoracic esophagectomy in terms of perioperative outcomes, serum cytokine levels, and respiratory function after surgery for esophageal cancer.

Methods

Patients who underwent a robot-assisted transmediastinal esophagectomy or transthoracic esophagectomy between April 2015 and March 2017 were included. The perioperative outcomes, preoperative and postoperative serum IL-6, IL-8, and IL-10 levels, and respiratory function measured preoperatively and at 6 months postoperatively were compared in patients with a robot-assisted transmediastinal esophagectomy and those with a transthoracic esophagectomy.

Results

Sixty patients with esophageal cancer were enrolled. The transmediastinal esophagectomy group had a significantly lower incidence of postoperative pneumonia (p = 0.002) and a significantly shorter postoperative hospital stay (p < 0.0002). The serum IL-6 levels on postoperative days 1, 3, 5, and 7 were significantly lower in the transmediastinal esophagectomy group (p = 0.005, 0.0007, 0.022, 0.020, respectively). In the latter group, the serum IL-8 level was significantly lower immediately after surgery and on postoperative day 1 (p = 0.003, 0.001, respectively) while the serum IL-10 level was significantly lower immediately after surgery (p = 0.041). The reduction in vital capacity, percent vital capacity, forced vital capacity, and forced expiratory volume at 1.0 s 6 months after surgery was significantly greater in the transthoracic esophagectomy group (p < 0.0001 for all four measurements).

Conclusions

Although further, large-scale studies are needed to confirm our findings, robot-assisted transmediastinal esophagectomy may confer short-term benefits in radical surgery for esophageal cancer.

Trial registration

This trial was registered in the UMIN Clinical Trial Registry (UMIN000017565 14/05/2015).

[Initial experience of robot-assisted minimally invasive McKeown esophagectomy]

OBJECTIVE

To report our initial experience of robot-assisted McKeown esophagectomy with stapled cervical esophagogastrostomy.

MATERIAL AND METHODS

There were 5 robot-assisted McKeown esophagectomies in patients with benign end-staged and malignant diseases of the esophagus for the period from October 2019 to February 2020.

RESULTS

No conversions and intraoperative complications were observed. Mean surgery time was 406±48 min, total intraoperative blood loss - 108±45 ml. Four patients had minor complications (wound infection, atelectasis, pneumothorax) that required conservative treatment. We have controlled anastomosis in 2-3 postoperative days with water-soluble contrast, none patient had an anastomotic leakage. Mean hospital-stay was 5 days. Complete (R0) resection was accomplished in all patients with malignant neoplasms.

CONCLUSIONS

Our first experience showed that robot-assisted McKeown esophagectomy is a safe and feasible surgical option for esophageal diseases. Robot-assisted interventions require advanced endoscopic surgical experience.

Robot-assisted cervical esophagectomy: first clinical experiences and review of the literature

Pulmonary complications, and especially pneumonia, remain one of the most common complications after esophagectomy for esophageal cancer. These complications are reduced by minimally invasive techniques or by avoiding thoracic access through a transhiatal approach. However, a transhiatal approach does not allow for a full mediastinal lymphadenectomy. A transcervical mediastinal esophagectomy avoids thoracic access, which may contribute to a decrease in pulmonary complications after esophagectomy. In addition, this technique allows for a full mediastinal lymphadenectomy. A number of pioneering studies have been published on this topic. Here, the initial experience is presented as well as a review of the current literature concerning transcervical esophagectomy, with a focus on the robot-assisted cervical esophagectomy procedure.

Robot-assisted minimally invasive esophagectomy for esophageal cancer: Meticulous surgery minimizing postoperative complications

Minimally invasive esophagectomy (MIE) has been reported to reduce postoperative complications especially pulmonary complications and have equivalent long-term survival outcomes as compared to open esophagectomy. Robot-assisted minimally invasive esophagectomy (RAMIE) using da Vinci surgical system (Intuitive Surgical, Sunnyvale, USA) is rapidly gaining attention because it helps surgeons to perform meticulous surgical procedures. McKeown RAMIE has been preferably performed in East Asia where squamous cell carcinoma which lies in more proximal esophagus than adenocarcinoma is a predominant histological type of esophageal cancer. On the other hand, Ivor Lewis RAMIE has been preferably performed in the Western countries where adenocarcinoma including Barrett esophageal cancer is the most frequent histology. Average rates of postoperative complications have been reported to be lower in Ivor Lewis RAMIE than those in McKeown RAMIE. Ivor Lewis RAMIE may get more attention for thoracic esophageal cancer. The studies comparing RAMIE and MIE where recurrent nerve lymphadenectomy was thoroughly performed reported that the rate of recurrent nerve injury is lower in RAMIE than in MIE. Recurrent nerve injury leads to serious complications such as aspiration pneumonia. It seems highly probable that RAMIE is beneficial in performing recurrent nerve lymphadenectomy. Surgery for esophageal cancer will probably be more centralized in hospitals with surgical robots, which enable accurate lymph node dissection with less complications, leading to improved outcomes for patients with esophageal cancer. RAMIE might occupy an important position in surgery for esophageal cancer.

Current Issues in Minimally Invasive Esophagectomy

Minimally invasive esophagectomy (MIE) was first introduced in the 1990s. Currently, it is a widely accepted surgical approach for the treatment of esophageal cancer, as it is an oncologically sound procedure; its advantages when compared to open procedures, including reduction in postoperative complications, reduction in the length of hospital stay, and improvement in quality of life, are well documented. However, debates are still ongoing about the safety and efficacy of MIE. The present review focuses on some of the current issues related to conventional MIE and robot-assisted MIE based on evidence from the current literature.

Essential Updates 2018/2019: Essential Updates for esophageal cancer surgery

Key papers to treatment of esophageal cancer surgery and reduction of postoperative complications after esophagectomy published between 2018 and 2019 were reviewed. Within this review there was a focus on minimally invasive esophagectomy (MIE), robot-assisted MIE (RAMIE), and centralization to high-volume center. Advantages of MIE, irrespectively of hybrid or total MIE, to prevent postoperative complications, especially pneumonia, were shown in comparison to open procedure. However, whether total MIE has evident effects or not, as compared to hybrid MIEs, still remains unclear. Differences between RAMIE and MIE were reported to be marginal, though the advantage of lymphadenectomy, especially along recurrent laryngeal nerve, has been suggested. Centralization to high-volume center evidently benefits esophageal cancer patients by improving short-term outcomes. The definition of high-volume center has not been established yet, though institutional structure and quality are thought to be important. Transmediastinal esophagectomy, currently developed, has a potential to be one radical option of MIE for esophageal cancer.

Postoperative complications of minimally invasive esophagectomy for esophageal cancer

Minimally invasive esophagectomy (MIE) has been performed increasingly more frequently for the treatment of esophageal cancer, ever since it was first described in 1992. However, the incidence of postoperative complications of MIE has not yet been well-characterized, because (a) there are few reports of studies with a sufficient sample size, (b) a variety of minimally invasive surgical techniques are used, and (c) there are few reports in which an established system for classifying the severity of complications is examined. According to an analysis performed by the Esophageal Complications Consensus Group, the most common complications of MIE are pneumonia, arrhythmia, anastomotic leakage, conduit necrosis, chylothorax, and recurrent laryngeal nerve palsy. Therefore, we decided to focus on these complications. We selected 48 out of 1245 reports of studies (a) that included more than 50 patients each, (b) in which the esophagectomy technique used was clearly described, and (c) in which the complications were adequately described. The overall incidences of the postoperative complications of MIE for esophageal cancer were analyzed according to the MIE technique adopted, that is, McKeown MIE, Ivor Lewis MIE, robotic-assisted McKeown MIE, robotic-assisted Ivor Lewis MIE, or mediastinoscopic transmediastinal esophagectomy. Pneumonia, arrhythmia, anastomotic leakage, and recurrent laryngeal nerve palsy occurred at an incidence rate of about 10% each; Ivor Lewis MIE was associated with a relatively low incidence of recurrent laryngeal nerve palsy. It is important to recognize that the incidences of complications of MIE are influenced by the MIE technique adopted and the extent of lymph node dissection.

Esophageal Position Affects Short-Term Outcomes After Minimally Invasive Esophagectomy: A Retrospective Multicenter Study

BACKGROUND

Anatomical esophageal position may affect the short-term outcomes after minimally invasive esophagectomy (MIE). A previous single-institutional retrospective study suggested that the presence of a left-sided esophagus (LSE) made MIE more difficult and increased the incidence of postoperative complications.

METHODS

The current study was a multicenter retrospective study of 303 patients with esophageal cancer who underwent MIE at six esophageal cancer high-volume centers in Kyushu, Japan, between April 2011 and August 2016. The patients were divided into the LSE (66 patients) and non-LSE groups (237 patients) based on the esophageal position on computed tomography images obtained with the patients in the supine position.

RESULTS

Univariate analysis showed that patients with LSE were significantly older than those with non-LSE (69 ± 8 vs. 65 ± 9 years; P = 0.002), had a significantly greater incidence of cardiovascular comorbidity (65.2% vs. 47.7%; P = 0.013), and a significantly longer operating time (612 ± 112 vs. 579 ± 102 min; P = 0.025). Logistic regression analysis verified that LSE was an independent risk factor for the incidence of pneumonia (odds ratio 3.3, 95% confidence interval 1.254-8.695; P = 0.016).

CONCLUSIONS

The presence of a LSE can increase the procedural difficulty of MIE and the incidence of morbidity after MIE. Thus, careful attention must be paid to anatomical esophageal position before performing MIE.

Transmediastinal approach for esophageal cancer: A new trend toward radical surgery

Esophageal squamous cell carcinoma (ESCC), the most common histology of esophageal cancer in Japan and Asia, shows extensive mediastinal spread from an early stage. Therefore, transthoracic esophagectomy with extensive mediastinal lymphadenectomy, including in the upper mediastinum along the recurrent laryngeal nerves, is the gold standard of radical surgery for ESCC. Minimally invasive thoracoscopic esophagectomy has now become a standard option for ESCC. However, transhiatal esophagectomy is regarded as less invasive because it avoids thoracotomy. Yet, it is also considered less curative because it offers a limited surgical view and insufficient mediastinal lymphadenectomy even when conventional specialized mediastinoscopy is used. Recent clinical studies on radical esophagectomy without thoracotomy for ESCC have been reported from Japan. The introduction of novel minimally invasive techniques for the transcervical or transhiatal approach, such as single-port or robotic surgical devices, have enabled transmediastinal radical esophagectomy for ESCC. This review focuses on the transmediastinal approach for esophageal cancer surgery, which employs minimally invasive techniques to reduce morbidity, and its application to radical surgery for ESCC.