Conversion to open surgery during minimally invasive esophagectomy portends worse short-term outcomes: an analysis of the National Cancer Database

Analyzing the emergence of surgical robotics in Africa: a scoping review of pioneering procedures, platforms utilized, and outcome meta-analysis

Purpose

Surgical practice globally has undergone significant advancements with the advent of robotic systems. In Africa, a similar trend is emerging with the introduction of robots into various surgical specialties in certain countries. The need to review the robotic procedures performed, platforms utilized, and analyze outcomes such as conversion, morbidity, and mortality associated with robotic surgery in Africa, necessitated this study. This is the first study examining the status and outcomes of robotic surgery in Africa.

Methods

A thorough scoping search was performed in PubMed, Google Scholar, Web of Science, and African Journals Online. Of the 1,266 studies identified, 16 studies across 3 countries met the inclusion criteria. A meta-analysis conducted using R statistical software estimated the pooled prevalences with the 95% confidence interval (CI) of conversion, morbidity, and mortality.

Results

Surgical robots are reportedly in use in South Africa, Egypt, and Tunisia. Across four specialties, 1,328 procedures were performed using da Vinci (Intuitive Surgical), Versius (CMR Surgical), and Senhance (Asensus Surgical) surgical robotic platforms. Urological procedures (90.1%) were the major procedures performed, with robotic prostatectomy (49.3%) being the most common procedure. The pooled rate of conversion and prevalence of morbidity from the meta-analysis was 0.21% (95% CI, 0%-0.54%) and 21.15% (95% CI, 7.45%-34.85%), respectively. There was no reported case of mortality.

Conclusion

The outcomes highlight successful implementation and the potential for wider adoption. Based on our findings, we advocate for multidisciplinary and multinational collaboration, investment in surgical training programs, and policy initiatives aimed at addressing barriers to the widespread adoption of robotic surgery in Africa.

Outcomes of minimally invasive vs. open pancreatoduodenectomies in pancreatic adenocarcinoma: analysis of ACS-NSQIP data

INTRODUCTION

Pancreatoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) presents a significant challenge owing to its aggressive nature. Traditionally performed as open surgery, the advent of minimally invasive surgery (MIS) including laparoscopic and robotic techniques, offers a potential alternative. This study assessed the use and outcomes of MIS and open PD for PDAC treatment.

METHODS

We analyzed ACS-NSQIP data (2015-2021) using regression models to compare patient outcomes across open PD, MIS PD, and conversions from MIS to open (MIS-O).

RESULTS

Of 19,812 PDAC patients, 1,293 (6.53%) underwent MIS, 18,116 (91.44%) underwent open PD, and 403 (2.03%) underwent MIS converted to open PD (MIS-O). The MIS rate increased from 6.1% to 9.2%. Black patients had a higher MIS-O rate (RR, 1.55; p = 0.025). Open PD was associated with more severe conditions (ASA ≥ III, malnutrition) and prior radiation therapy. MIS patients more often had neoadjuvant chemotherapy. Complex procedures, such as vein resection, favored open PD. Need for arterial resection was associated with MIS-O (RR, 2.11; p = 0.012), and operative time was significantly associated with MIS (OR: 4.32, 95% CI: 3.43-5.43, p-value: < 0.001) No differences in the overall morbidity or 30-day mortality were observed. MIS led to shorter stays but higher risks of reoperation and pulmonary embolism. MIS-O increased the delayed gastric emptying rate (RR, 1.79; p < 0.001).

CONCLUSION

During 2015-2021, an increasing number of patients with PDAC are undergoing MIS PD. Morbidity and mortality did not differ between open and MIS PD. MIS was performed more frequently in patients with better nutritional status and lower ASA, or when vascular resection was not anticipated. In well selected patients, short-term outcomes of MIS and open PD seem similar.

Unplanned conversions of robotic pancreaticoduodenectomy: short-term outcomes and suggested stepwise approach for a safe conversion

OBJECTIVE

With the increased adoption of robotic pancreaticoduodenectomy, the effects of unplanned conversions to an 'open' operation are ill-defined. This study aims to describe the impact of unplanned conversions of robotic pancreaticoduodenectomy on short-term outcomes and suggest a stepwise approach for safe unplanned conversions during robotic pancreaticoduodenectomy.

METHODS

This is an analysis of 400 consecutive patients undergoing robotic pancreaticoduodenectomy in a single high-volume institution. Data are presented as median (mean ± SD), and significance is accepted with 95% probability.

RESULTS

Between November 2012 and February 2023, 184 (46%) women and 216 (54%) men, aged 70 (68 ± 11.0) years, underwent a robotic pancreaticoduodenectomy. Unplanned conversions occurred in 42 (10.5%) patients; 18 (5%) were converted due to unanticipated vascular involvement, 13 (3%) due to failure to obtain definitive control of bleeding, and 11 (3%) due to visceral obesity. Men were more likely to require a conversion than women (29 vs. 13, p = 0.05). Conversions were associated with shorter operative time (376 (323 ± 182.2) vs. 434 (441 ± 98.7) min, p < 0.0001) but higher estimated blood loss (675 (1010 ± 1168.1) vs. 150 (196 ± 176.8) mL, p < 0.0001). Patients that required an unplanned conversion had higher rates of complications with Clavien-Dindo scores of   III-V (31% vs. 12%, p = 0.003), longer length of stay (8 (11 ± 11.6) vs. 5 (7 ± 6.2), p = 0.0005), longer ICU length of stay (1 (2 ± 5.1) vs. 0 (0 ± 1.3), p < 0.0001) and higher mortality rates (21% vs. 4%, p = 0.0001). The conversion rate significantly decreased over time (p < 0.0001).

CONCLUSIONS

Unplanned conversions of robotic pancreaticoduodenectomy significantly and negatively affect short-term outcomes, including postoperative mortality. Men were more likely to require a conversion than women. The unplanned conversions rates significantly decreased over time, implying that increased proficiency and patient selection may prevent unplanned conversions. An unplanned conversion should be undertaken in an organized stepwise approach to maximize patient safety.

The Effect of Neoadjuvant Therapy on Esophagectomy for cT2N0M0 Esophageal Adenocarcinoma

BACKGROUND

For cT2N0M0 esophageal adenocarcinomas, the effects of neoadjuvant chemoradiotherapy (NT) on surgical outcomes and the oncological benefits to the patients are debatable. In this study, we investigated the optimal management for cT2N0M0 adenocarcinoma (1) assessing the perioperative impact of NT on esophagectomy and (2) evaluating the oncologic effect of NT in a homogeneous group of patients with clinical stage IIA. We hypothesized that NT does not negatively affect perioperative outcomes and provides an oncologic benefit to selected patients with cT2N0M0 disease.

METHODS

The National Cancer Database was queried (2010-2019) for patients with cT2N0M0 esophageal adenocarcinoma undergoing esophagectomy. After propensity-matching to adjust for differences in patient and tumor characteristics, we compared postoperative outcomes (logistic regression) and survival (Kaplan-Meier and Cox regression) among those who underwent NT vs upfront surgery (S).

RESULTS

This study included 3413 patients, of whom 2359 (69%) received NT, and 1054 (31%) S. In contrast to those who underwent S, in the matched cohort, patients treated with NT had comparable conversion rates (8% vs11.1%, p = 0.06), length of stay (9 vs 10 days, p = 0.078), unplanned readmission (5.4% vs 8.8%, p = 0.109), and 30- (3.9% vs 3.7%, p = 0.90) and 90-day mortality (5.7% vs 4.7%, p = 0.599). In addition, NT associated with improved survival in patients with cT2N0M0 tumors > 5 cm (HR 0.30, 95% CI 0.17-0.36).

CONCLUSIONS

NT does not appear to increase technical complexity or to adversely affect postoperative outcomes after esophagectomy. Furthermore, minimally invasive esophagectomy is feasible following NT, with comparable conversion rates to those who had upfront surgery. Lastly, NT was selectively associated with improved survival in patients with cT2N0M0 esophageal cancer.

Lower Rates of Unplanned Conversion to Open in Robotic Approach to Esophagectomy for Cancer

BACKGROUND

Minimally invasive approaches to esophagectomy have gained popularity worldwide; however, unplanned conversion to an open approach is not uncommon. This study sought to investigate risk factors associated with converting to an open approach and to evaluate outcomes following conversion.

METHODS

Patients undergoing minimally invasive esophagectomy (MIE) for cancer were identified using the 2016-2019 Procedure Targeted NSQIP Database. Multivariable, stepwise logistic regression analysis was performed to investigate factors associated with unplanned conversion to open esophagectomy. Propensity-matched comparison of robotic (RAMIE) to traditional MIE was performed.

RESULTS

A total of 1347 patients were included; 140 patients (10%) underwent conversion to open. Morbid obesity, diabetes, hypertension, American Society of Anesthesiologists class, and squamous cell carcinoma were associated with a higher likelihood of conversion. A robotic approach was associated with a lower likelihood of conversion to open (OR .57, 95% CI 0.32-.99). On multivariable analysis, squamous cell carcinoma pathology was the only variable independently associated with higher odds of conversion (OR 2.66, 95% CI 1.02-6.98). Propensity-matched comparison of RAMIE vs MIE showed no significant difference in conversion rate (6.5% vs 9.1%, P = .298), morbidity, or mortality.

DISCUSSION

A robotic approach to esophagectomy was associated with a lower likelihood of unplanned conversion to open, and patients who were converted to open experienced worse outcomes. Future studies should aim to determine why a robotic esophagectomy approach may lead to fewer open conversions as it may be an underappreciated benefit of this newest operative approach.

Hybrid Minimally Invasive Esophagectomy for Carcinoma Oesophagus: Experience at Tertiary Care Centre in North Karnataka

Surgery remains the mainstay for curative treatment of carcinoma of midthoracic and lower thoracic oesophagus. In the twentieth century, open esophagectomy was the standard of care. In the twenty-first century, treatment for carcinoma oesophagus has revolutionized with incorporation of neoadjuvant treatment and application of various minimally invasive techniques for esophagectomy. At present, there is no consensus about the optimum position to perform minimally invasive esophagectomy (MIE). We share our experience of MIE with modification in the port position in this article.

Conversion to Thoracotomy in Non-Small Cell Lung Cancer: Risk Factors and Perioperative Outcomes

Objective: We aimed to identify predictors of conversion to thoracotomy and test the hypothesis that conversion is associated with inferior perioperative outcomes in non-small cell lung cancer (NSCLC). Methods: We queried the National Cancer Database for patients with stage I to III NSCLC undergoing minimally invasive surgery (MIS) during 2010 to 2016. We compared clinicopathologic factors between patients undergoing MIS with and without conversion. We fitted multivariable regression models to identify independent predictors of conversion and compare perioperative outcomes between the 2 groups. Results: A rising trend in the use of MIS was accompanied by a declining trend in the rate of conversion to thoracotomy. A total of 11.3% of the 83,219 cases were converted. Conversion was associated with a higher Charlson-Deyo score, squamous histology, nodal involvement, high tumor grade, tumor size ≥5 cm, and a higher T stage ( P < 0.05). Successful MIS without conversion was predicted by advanced age, sublobar resection, robotic approach, and treatment at an academic high-volume facility ( P < 0.05). Conversion was linked to longer hospital stays, higher 30-day and 90-day mortality, and unplanned readmission ( P < 0.05), irrespective of the type of MIS approach. Conclusions: Conversion rates for video-assisted and robot-assisted thoracoscopic surgery have seen a decline in recent years. Irrespective of the type of MIS approach, conversion was associated with inferior perioperative outcomes. The robotic approach and treatment at an academic high-volume facility were associated with a lower likelihood of conversion. Early recognition of the individual risk factors for conversion may help to counsel patients about the likelihood of, and detriments associated with, conversion and ultimately reduce conversion rates.

Conversion to Open Radical or Partial Nephrectomy Associated with Unplanned Hospital Readmission After Attempted Minimally Invasive Approach

Introduction/Objectives: We endeavored to explore the rates of unplanned hospital readmission (UHR) in patients who underwent minimally invasive radical or partial nephrectomy who were subsequently converted to open surgery. Patients and Methods: The National Cancer Database (NCDB) was used for this study. Patients diagnosed with renal cancer and who had minimally invasive partial or radical nephrectomy from 2004 to 2016 were included in the study. Patients were categorized as converted or not converted to open surgery. UHR was the outcome of the study and was defined as UHR within 30 days of discharge. We conducted a one-to-one nearest-neighbor propensity-score matching using baseline clinical, tumor, and facility characteristics. To evaluate the relationship between conversion to open surgery and UHR, we conducted a multivariable logistic regression on the propensity-matched cohort, a propensity score-matched model without controlling for any covariate, and a propensity score-adjusted model, controlling for only the propensity score. Results: A total of 142,040 patients were identified, with a 2.98% conversion rate. There was an overall decrease in the rate of conversion to open surgery from 2010 (4.11%) to 2016 (2.43%). Laparoscopic radical nephrectomy remained a significant contributor to the rate of conversion (at least 50% per year). In the unmatched cohort, the UHR rate was higher among those who had a conversion to open surgery (n = 710, 0.52% versus n = 44, 1.04%; P < .001). Similarly, in the propensity score-matched cohort, the UHR rate was higher among those who had a conversion to open (n = 22, 0.52% versus n = 44, 1.04%; P = .007). After controlling for other factors, conversion to open remained independently associated with UHF. Conclusion: Conversion to open radical or partial nephrectomy from a minimally invasive approach is independently associated with an increased risk of 30-day UHR.

Robot-assisted minimally invasive esophagectomy versus video-assisted minimally invasive esophagectomy: a systematic review and meta-analysis

Background

Robot-assisted minimally invasive esophagectomy (RAMIE) has been demonstrated to offer realistic three-dimensional visual clarity, flexible movement and so on. The high cost is the main reason hampering universal application. The aim of this study was to compare the short-term outcomes of RAMIE versus video-assisted minimally invasive esophagectomy (VAMIE).

Methods

The PubMed, EMBASE and Web of Science databases were systematically searched up to June 1, 2021, for studies comparing RAMIE and VAMIE.

Results

Nineteen studies were enrolled, which consisted of a total of 4,714 patients, including 2,306 patients in the RAMIE group and 2,408 patients in the VAMIE group. In RAMIE patients, higher numbers of total lymph nodes (MD =0.171, 95% CI: 0.086–0.255, P<0.001) and lymph nodes along the left recurrent laryngeal nerve (RLN) (MD =0.219, 95% CI: 0.097–0.340, P<0.001) were removed. In RAMIE patients in the McKown group, higher numbers of total lymph nodes (MD =0.173, 95% CI: 0.080–0.265, P<0.001) and lymph nodes along the left RLN (MD =0.220, 95% CI: 0.090–0.350, P=0.001) were removed, while in those in the ESCC group, higher numbers of total lymph nodes (MD =0.249, 95% CI: 0.091–0.407, P=0.002) and lymph nodes along the left RLN (MD =0.239, 95% CI: 0.102–0.377, P=0.001) were removed.

Discussion

This study indicated that the main advantage of RAMIE was a greater number of harvested lymph nodes, which may be beneficial to diagnosis and local control. RCTs with larger sample sizes and studies reporting long-term outcomes are needed to evaluate the advantages and disadvantages of RAMIE and VAMIE.

Robotic esophagectomy: results from a tertiary care Italian center

There is growing evidence supporting the use of minimally invasive resection in esophageal surgery, mainly due to reduced postoperative morbidity and faster recovery after surgery. In recent years, robot-assisted surgery has shown some potential benefits over conventional laparo-thoracoscopic esophagectomy. The purpose of this study is to report our experience with different esophageal resections with a full-robotic approach for malignant disease. All consecutive patients with resectable esophageal malignancy undergoing robotic esophagectomy over a 6-year time frame by a single surgical team were included in this analysis. Perioperative and clinicopathological outcomes were assessed. A total of 76 patients received robotic esophagectomy. Surgeries included 45 Lewis procedures, 25 McKeown procedures, and six transhiatal resections. There were no intraoperative complications and no conversions occurred. The rate of postoperative morbidity was 41%, while the rate of anastomotic leak was 13%. Overall, eight patients required reintervention. All patients received R0 resection, with a median of harvested lymph nodes of 35. 30-day and 90-day mortality was 3.9 and 7.9%, respectively. Our findings support the safety and oncological efficiency of full-robotic esophagectomy. All procedures of esophageal resection were associated with the expected perioperative morbidity while providing excellent pathological outcomes for patients with malignancy.

Outcomes After Converted Minimally Invasive to Open Esophagectomy in Patients With Esophageal Cancer

BACKGROUND

The objective of this study was to evaluate the impact of unplanned conversion to open esophagectomy during minimally invasive esophagectomy (MIE) on postoperative morbidity and mortality for patients with esophageal cancer, as well as to evaluate the variables that influence the need for conversion.

METHODS

This study was a retrospective analysis of patients with esophageal cancer who underwent open esophagectomy or MIE by either a laparothoracoscopic approach or a robotic approach from 2016 to 2018 by using the esophagectomy-specific American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Poisson regression models were used to analyze 30-day outcomes and risk factors for conversion to open esophagectomy during attempted MIE.

RESULTS

A total of 2616 patients were identified. The overall conversion rate for MIE was 6.3%. Compared with completed MIE, patients requiring conversion to open esophagectomy had a significantly increased risk of 30-day mortality (risk ratio, 2.63; 95% confidence interval, 1.03 to 6.69) and experienced a variety of other postoperative complications. Patients requiring conversion to open esophagectomy during MIE also experienced worse perioperative outcomes when compared to patients who underwent planned open esophagectomy. Estimated surgical risk on the basis of the ACS NSQIP Surgical Risk Calculator was the only variable found to be independently associated with conversion from minimally invasive to open esophagectomy (risk ratio, 1.03; 95% confidence interval, 1.01 to 1.04, for each 10% increase in risk score).

CONCLUSIONS

Unplanned conversion to open esophagectomy during MIE is associated with significantly greater morbidity and a 2.6-fold increased risk of death when compared with both completed MIE and planned open esophagectomy. The ACS NSQIP Surgical Risk Calculator may help identify patients preoperatively who are at higher risk for conversion to open esophagectomy during MIE.

Laparoscopic-assisted Esophageal Bypass for T4b Esophageal Tumor as a Bridge to Definitive Therapy

BACKGROUND/AIM

Esophagobronchial fistula is a common complication of advanced esophageal cancer, related to respiratory distress and mortality. Esophageal bypass has been successfully utilized for palliation, as bridging to definitive chemoradiotherapy. The aim of this study is to present an extremely difficult case of a mid-esophageal squamous cell carcinoma complicated with aerodigestive fistula that was treated using 3D laparoscopic-assisted esophageal bypass with curative intent.

CASE REPORT

A 49-year-old female patient presented with T4b esophageal-squamous cell carcinoma and esophagobronchial fistula. Laparoscopic-assisted V-shaped retrosternal esophageal bypass using a gastric conduit was started, which was converted to open surgery due to respiratory distress. The patient was able to undergo chemoradiotherapy treatment.

CONCLUSION

3D laparoscopic-assisted esophageal bypass can be a safe and feasible approach in patients with advanced mid-esophageal squamous cell carcinoma and esophagobroncial fistula. Additionally to the advantages of laparoscopic surgery, this operation permits oral feeding, and can be used with possible curative intent in patients with adequate response to chemoradiotherapy.