Robot-assisted minimally invasive esophagectomy (RAMIE) compared to conventional minimally invasive esophagectomy (MIE) for esophageal cancer: a propensity-matched analysis

Single-Port Robot-Assisted Minimally Invasive Esophagectomy Using the Single-Port Robotic System via the Subcostal Approach: A Single-Center Retrospective Study

BACKGROUND

Robot-assisted minimally invasive esophagectomy (RAMIE) has gained global popularity. Recent randomized controlled trials have demonstrated that RAMIE results in reduced operative times and a greater number of dissected lymph nodes compared to conventional minimally invasive esophagectomy (MIE). This study provides an initial analysis of single-port (SP) robot-assisted minimally invasive esophagectomy (SRAMIE) using the SP robotic system via the subcostal approach. The primary objective is to examine perioperative outcomes of SRAMIE compared to multi-port RAMIE (MRAMIE) using the Xi robotic system and video-assisted thoracoscopic esophagectomy (VAE).

METHODS

In this retrospective study, patients who underwent MIE at a single center between February 2017 and December 2024 were analyzed. Patients were divided into SRAMIE (n = 17), MRAMIE (n = 13), and VAE (n = 23) groups. The primary outcome was the incidence of postoperative complications. Secondary outcomes included chest tube duration, length of postoperative hospital stay, postoperative pain levels, and 30-day mortality.

RESULTS

The SRAMIE group did not experience conversions to thoracotomy or VAE. Compared with VAE, SRAMIE resulted in significantly shorter chest tube duration (p = 0.038), shorter postoperative hospital stays (p = 0.036), and lower peak postoperative pain (p = 0.003). No significant differences were observed among the groups regarding the total operative time, number of resected lymph nodes, or incidence of postoperative complications.

CONCLUSIONS

SRAMIE is a feasible approach offering advantages over VAE in recovery and postoperative pain. The comparable perioperative outcomes suggest that SRAMIE may be a viable alternative to conventional MIE, warranting further large-scale studies.

What is the best surgical approach for esophageal cancer?

Esophageal cancer is an aggressive tumor entity, and oncologic esophagectomy with two-field lymphadenectomy after perioperative chemotherapy or chemoradiotherapy is the standard of care for curative treatment. Oncological esophagectomy is a complex procedure associated with a relevant surgical trauma. Complications, such as severe pulmonary infections and anastomotic leakage with mediastinitis lead to a high morbidity rate. To reduce the surgical trauma, the minimally invasive technique was introduced in esophageal surgery. Minimally invasive esophagectomy is associated with less postoperative pain and a reduced rate of pulmonary infections. Currently, there are two major different totally minimally invasive techniques, the conventional laparoscopic/thoracoscopic approach (MIE) and the robotic assisted approach (RAMIE). Both methods require teaching due to the flat learning curve associated with these complex procedures. However, both MIE and RAMIE are performed safely in specialized centers. They are associated with improved short-term outcome and similar oncological outcome compared to open esophagectomy. The robotic assisted approach has additional benefits that may be supported by the results of more randomized controlled trials in the future.

Textbook outcome after robotic and laparoscopic Ivor Lewis esophagectomy is associated with improved survival: A propensity score-matched analysis

BACKGROUND

Esophagectomy is central to curative therapy for esophageal cancer (EC). Perioperative outcomes affect both disease-free survival (DFS) and overall survival (OS) in patients undergoing oncologic esophageal surgery. The adoption of robotic techniques may improve surgical outcomes; however, the complex nature of perioperative outcomes is not adequately captured by individual quality measures.

METHODS

All EC patients after minimally invasive esophagectomy (MIE) or robotic-assisted MIE (RAMIE) junction between 2015 and 2022 were included. Textbook outcome (TO) was defined as negative resection margin (R0), retrieval of >20 lymph nodes, no major complications, no reinterventions, no intensive care unit readmission, no 30-day readmission or mortality, and hospital stay <21 days. Individual propensity scores were calculated using a logistic regression model. Factors affecting TO were evaluated using a logistic regression model, and a multivariate Cox proportional hazards model was used to evaluate TO and survival.

RESULTS

Of 236 patients included in this study, 106 (44.91%) achieved TO. TO was achieved in 71 patients after MIE (41.21%) and in 31 patients after RAMIE (57.41%; P = .036). RAMIE was associated with achievement of TO (odds ratio, 2.01; 95% confidence interval [CI], 1.07-3.80; P = .031) in the overall cohort. Achievement of TO was due to a reduction in major complications in the RAMIE group. Patients with perioperative TO had higher 3-year DFS and OS rates (univariate analysis [UV]: hazard ratio [HR], 2.49; 95% CI, 1.18-5.26; P = .016; multivariate analysis [MV]: HR, 4.30; 95% CI, 1.60-11.55; P = .004) compared to those without perioperative TO and disease-free survival (UV: HR, 2.28; 95% CI, 1.24-4.19; P = .008; MV: HR, 2.82; 95% CI, 1.26-6.32; P = .011) at the 2-year follow-up.

CONCLUSIONS

RAMIE is associated with increased TO achievement. Achieving TO is associated with enhanced long-term survival in EC patients and warrants continued emphasis on surgical quality improvement.

Caseload per Year in Robotic-Assisted Minimally Invasive Esophagectomy: A Narrative Review

Esophageal surgery is deemed one of the most complex visceral operations. There is a well-documented correlation between higher caseload and better outcomes, with hospitals that perform more surgeries experiencing significantly lower mortality rates. The approach to caseload per year varies across different countries within Europe. Germany increased the minimum annual required caseload of complex esophageal surgeries from 10 to 26 starting in 2023. Furthermore, the new regulations present challenges for surgical training and staff recruitment, risking the further fragmentation of training programs. Enhanced regional cooperation is proposed as a solution to ensure comprehensive training. This review explores the benefits of robotic-assisted minimally invasive esophagectomy (RAMIE) in improving surgical precision and patient outcomes and aims to evaluate how the caseload per year influences the quality of patient care and the efficacy of surgical training, especially with the integration of advanced robotic techniques.

Efficacy and prognostic analysis of carbon nanotracers combined with the da Vinci robot in the treatment of esophageal cancer

BACKGROUND

Traditional methods cannot clearly visualize esophageal cancer (EC) tumor contours and metastases, which limits the clinical application of da Vinci robot-assisted surgery.

AIM

To investigate the efficacy of the da Vinci robot in combination with nanocarbon lymph node tracers in radical surgery of EC.

METHODS

In total, 104 patients with early-stage EC who were admitted to Liuzhou worker's Hospital from January 2020 to June 2023 were enrolled. The patients were assigned to an observation group (n = 52), which underwent da Vinci robot-assisted minimally invasive esophagectomy (RAMIE) with the intraoperative use of nanocarbon tracers, and a control group (n = 52), which underwent traditional surgery treatment. The operation time, intraoperative blood loss, postoperative drainage tube indwelling time, hospital stay, number of lymph nodes dissected, incidence of complications, and long-term curative effects were comparatively analyzed. The postoperative stress response C-reactive protein (CRP), cortisol, epinephrine (E) and inflammatory response interleukin (IL)-6, IL-8, IL-10, and tumor necrosis factor-alpha (TNF-α) were evaluated.

RESULTS

Compared with the control group, the observation group had significantly lower postoperative CRP, cortisol, and E levels (P < 0.05) with a milder inflammatory response, as indicated by lower IL-6, IL-10, and TNF-α levels (P < 0.05). Patients who underwent RAMIE had less intraoperative blood loss and shorter operation times and hospital stays than those who underwent traditional surgery. The average number of dissected lymph nodes, time of lymph node dissection, and mean smallest lymph node diameter were all significantly lower in the observation group (P < 0.05). The rate of postoperative complications was 5.77% in the observation group, significantly lower than the 15.38% observed in the control group. Furthermore, the lymphatic metastasis rate, reoperation rate, and 12- and 24-month cumulative mortality in the observation group were 1.92%, 0%, 0%, and 0%, respectively, all of which were significantly lower than those in the control group (P < 0.05).

CONCLUSION

The treatment of EC using the da Vinci robot combined with nanocarbon lymph node tracers can achieve good surgical outcomes and demonstrates promising clinical applications.

Robotic-Assisted Ivor Lewis Esophagectomy

Robotic-assisted surgery is a safe and effective approach to minimally invasive Ivor Lewis esophagectomy. Outcomes are optimized when surgeons are familiar with the fundamentals of minimally invasive surgery of the esophagus and after gaining sufficient experience with robotic surgical techniques.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association of hospital volume and operative approach with clinical and financial outcomes of elective esophagectomy in the United States

INTRODUCTION

Literature regarding the impact of esophagectomy approach on hospitalizations costs and short-term outcomes is limited. Moreover, few have examined how institutional MIS experience affects costs. We thus examined utilization trends, costs, and short-term outcomes of open and minimally invasive (MIS) esophagectomy as well as assessing the relationship between institutional MIS volume and hospitalization costs.

METHODS

All adults undergoing elective esophagectomy were identified from the 2016-2020 Nationwide Readmissions Database. Multiple regression models were used to assess approach with costs, in-hospital mortality, and major complications. Additionally, annual hospital MIS esophagectomy volume was modeled as a restricted cubic spline against costs. Institutions performing > 16 cases/year corresponding with the inflection point were categorized as high-volume hospitals (HVH). We subsequently examined the association of HVH status with costs, in-hospital mortality, and major complications in patients undergoing minimally invasive esophagectomy.

RESULTS

Of an estimated 29,116 patients meeting inclusion, 10,876 (37.4%) underwent MIS esophagectomy. MIS approaches were associated with $10,600 in increased incremental costs (95% CI 8,800-12,500), but lower odds of in-hospital mortality (AOR 0.76; 95% CI 0.61-0.96) or major complications (AOR 0.68; 95% CI 0.60, 0.77). Moreover, HVH status was associated with decreased adjusted costs, as well as lower odds of postoperative complications for patients undergoing MIS operations.

CONCLUSION

In this nationwide study, MIS esophagectomy was associated with increased hospitalization costs, but improved short-term outcomes. In MIS operations, cost differences were mitigated by volume, as HVH status was linked with decreased costs in the setting of decreased odds of complications. Centralization of care to HVH centers should be considered as MIS approaches are increasingly utilized.

Advances in the Surgical Management of Esophageal Cancer

Radical esophagectomy with two or three-field lymphadenectomy remains the mainstay of curative treatment for localized esophageal cancer, often in combination with systemic chemotherapy and/or radiotherapy. In this article, we describe notable advances in the surgical management of esophageal cancer over the past decade that have led to an improvement in both surgical and oncologic outcomes. In addition, we discuss new approaches to surgical management currently under investigation that have the potential to offer further benefits to appropriately selected patients. These incremental breakthroughs primarily include advances in endoscopic and minimally invasive techniques, perioperative management protocols, as well as the application of local therapies, including surgery, to oligometastatic disease.

Robot-assisted oesophagectomy (Ivor-Lewis) for a complex stenosis previously managed by open gastrostomy tube placement

A man in his late 50s presented with severe dysphagia caused by a complex refractory benign stenosis that was completely obstructing the middle oesophagus. The patient was unsatisfied with the gastrostomy tube placed via laparotomy as a long-term solution. Therefore, we performed robot-assisted minimally invasive oesophagectomy (video). Mobilisation of the stomach and gastric conduit preparation were more difficult due to the previously inserted gastrostomy tube; thus, the conduit blood supply was assessed using indocyanine green fluorescence. After an uncomplicated course, the patient was referred directly to inpatient rehabilitation on the 16th postoperative day. At 9 months after surgery, the motivated patient returned to full-time work and achieved level 7 on the functional oral intake scale (total oral diet, with no restrictions). At the 1-year follow-up, he positively confirmed all nine key elements of a good quality of life after oesophagectomy.

Anterior gastric wall anastomosis may lead to lower rate of delayed gastric emptying after minimally invasive Ivor Lewis esophagectomy: a retrospective cohort study

INTRODUCTION

In minimally invasive esophagectomy, a circular stapled anastomosis is common, but no evidence exists investigating the role of the specific localization of the anastomosis. The aim of this study is to evaluate the impact of an esophagogastrostomy on the anterior or posterior wall of the gastric conduit on the postoperative outcomes.

MATERIAL AND METHODS

All oncologic minimally invasive Ivor Lewis procedures, performed between 2017 and 2022, were included in this study. The cohort was divided in two groups: a) intrathoracic esophagogastrostomy on the anterior gastric wall of the conduit (ANT, n = 285, 65%) and b) on the posterior gastric wall (POST, n = 154, 35%). Clinicopathological parameters and short-term outcomes were compared between both groups by retrieving data from the prospective database.

RESULTS

Overall, 439 patients were included, baseline characteristics were similar in both groups, there was a higher proportion of squamous cell carcinoma in ANT (22.8% vs. 16.2%, P = 0.043). A higher rate of robotic-assisted procedures was observed in ANT (71.2% vs. 49.4%). Anastomotic leakage rate was similar in both groups (ANT 10.4% vs. POST 9.8%, P = 0.851). Overall complication rate and Clavien-Dindo > 3 complication rates were higher in POST compared to ANT: 53.2% vs. 40% (P = 0.008) and 36.9% vs. 25.7% (P = 0.014), respectively. The rate of delayed gastric emptying (20.1% vs. 7.4%, P < 0.001) and nosocomial pneumonia (22.1% vs. 14.8%, P = 0.05) was significantly higher in POST.

CONCLUSION

Patients undergoing minimally invasive Ivor Lewis esophagectomy with an intrathoracic circular stapled anastomosis may benefit from esophagogastrostomy on the anterior wall of the gastric conduit, in terms of lower rate of delayed gastric emptying.

Long-term outcomes of robot-assisted versus minimally invasive esophagectomy in patients with thoracic esophageal cancer: a propensity score-matched study

BACKGROUND

Recently, robot-assisted minimally invasive esophagectomy (RAMIE) has gained popularity worldwide. Some studies have compared the long-term results of RAMIE and minimally invasive esophagectomy (MIE). However, there are no reports on the long-term outcomes of RAMIE in Japan. This study compared the long-term outcomes of RAMIE and MIE.

METHODS

This retrospective study included 86 patients with thoracic esophageal cancer who underwent RAMIE or MIE at our hospital from June 2010 to December 2016. Propensity score matching (PSM) was employed, incorporating co-variables such as confounders or risk factors derived from the literature and clinical practice. These variables included age, sex, body mass index, alcohol consumption, smoking history, American Society of Anesthesiologists stage, comorbidities, tumor location, histology, clinical TNM stage, and preoperative therapy. The primary endpoint was 5-year overall survival (OS), and the secondary endpoints were 5-year disease-free survival (DFS) and recurrence rates.

RESULTS

Before PSM, the RAMIE group had a longer operation time (min) than the MIE group (P = 0.019). RAMIE also exhibited significantly lower blood loss volume (mL) (P < 0.001) and fewer three-field lymph node dissections (P = 0.028). Postoperative complications (Clavien-Dindo: CD ≥ 2) were significantly lower in the RAMIE group (P = 0.04), and postoperative hospital stay was significantly shorter than the MIE group (P < 0.001). After PSM, the RAMIE and MIE groups consisted of 26 patients each. Blood loss volume was significantly smaller (P = 0.012), postoperative complications (Clavien-Dindo ≥ 2) were significantly lower (P = 0.021), and postoperative hospital stay was significantly shorter (P < 0.001) in the RAMIE group than those in the MIE group. The median observation period was 63 months. The 5-year OS rates were 73.1% and 80.8% in the RAMIE and MIE groups, respectively (P = 0.360); the 5-year DFS rates were 76.9% and 76.9% in the RAMIE and MIE groups, respectively (P = 0.749). Six of 26 patients (23.1%) in each group experienced recurrence, with a median recurrence period of 41.5 months in the RAMIE group and 22.5 months in the MIE group.

CONCLUSIONS

Compared with MIE, RAMIE led to no differences in long-term results, suggesting that RAMIE is a comparable technique.

Short-term outcomes of robot-assisted versus conventional minimally invasive esophagectomy for esophageal cancer: a systematic review and meta-analysis of 18,187 patients

The role of robotic surgery in the curative-intent treatment of esophageal cancer patients is yet to be defined. To compare short-term outcomes between conventional minimally invasive (cMIE) and robot-assisted minimally invasive esophagectomy (RAMIE) in esophageal cancer patients. PubMed, Web of Science and Cochrane Library were systematically searched. The included studies compared short-term outcomes between cMIE and RAMIE. Individual risk of bias was calculated using the MINORS and RoB2 scales. There were no statistically significant differences between RAMIE and cMIE regarding conversion to open procedure, mean number of harvested lymph nodes in the mediastinum, abdomen and along the right recurrent laryngeal nerve (RLN), 30- and 90-day mortality rates, chyle leakage, RLN palsy as well as cardiac and infectious complication rates. Estimated blood loss (MD - 71.78 mL, p < 0.00001), total number of harvested lymph nodes (MD 2.18 nodes, p < 0.0001) and along the left RLN (MD 0.73 nodes, p = 0.03), pulmonary complications (RR 0.70, p = 0.001) and length of hospital stay (MD - 3.03 days, p < 0.0001) are outcomes that favored RAMIE. A significantly shorter operating time (MD 29.01 min, p = 0.004) and a lower rate of anastomotic leakage (RR 1.23, p = 0.0005) were seen in cMIE. RAMIE has indicated to be a safe and feasible alternative to cMIE, with a tendency towards superiority in blood loss, lymph node yield, pulmonary complications and length of hospital stay. There was significant heterogeneity among studies for some of the outcomes measured. Further studies are necessary to confirm these results and overcome current limitations.

Learning curve in relation to health-related quality of life in long-term, disease free survivors after McKeown minimally invasive esophagectomy

BACKGROUND

The potential impact of learning curve on long-term health-related quality of life (QoL) after esophagectomy for cancer has not been investigated. The aim of this article is to investigate the relationship between learning curve for McKeown minimally invasive esophagectomy (MIE) and health-related quality of life (QoL) in long-term, disease free survivors up to 10 years after esophageal cancer resection.

METHODS

Esophageal cancer patients who underwent McKeown MIE between 2009 and 2019 were identified in which 280 who were free of disease at the time of survey and completed health-related QoL and symptom questionnaires, including EORTC QLQ-C30, EORTC QLQ-OES18, and Digestive Symptom Questionnaire. Patients were assessed in 3 cohorts according to the learning phases of expertise reported by our previous study: initial phase; plateau phase, and; experienced phase.

RESULTS

Median time from operation to survey was 5.8 years (interquartile range 4.6-8.2). The QLQ-C30 mean scores of functional scales, and symptom scales of respiratory and digestive systems including dyspnea (P = 0.006), shortness of breath (P = 0.003), and dysphagia (P = 0.031) were significantly better in experienced phase group. Furthermore, in the subgroup analyses for patients without postoperative major complications, patients in the initial learning phase remained suffering from more symptoms of dyspnea (P = 0.040) and shortness of breath (P = 0.001).

CONCLUSION

Esophageal cancer patients undergoing McKeown MIE in initial learning phase tend to suffer from a deterioration in long-term health-related QoL and higher symptomatic burden as compared to experienced learning phase, which did not improved over time and warranted more attention.

Comparison of clinical outcomes of robotic-assisted and video-assisted esophagectomy for esophageal cancer

INTRODUCTION

Robotic-assisted minimally invasive esophagectomy (RAMIE) is a recently developed technique for the treatment of resectable esophageal cancer. The present study compares the outcomes of RAMIE and video-assisted thoracoscopic esophagectomy (VATE).

METHOD

Patients undergoing minimally invasive esophageal surgery between December 2020 and September 2022 were included in the study, while those undergoing conventional surgery were excluded. The patients were divided into two groups, as those undergoing RAMIE (Group 1) and those undergoing VATE (Group 2). The demographic and clinical characteristics, intraoperative parameters, pathological data, and postoperative parameters of the groups were compared.

RESULTS

A total of 28 patients were included in the study, with 13 patients in Group 1 and 15 patients in Group 2. The gender distribution was similar (P = 0.488), and the mean age was 64.7 and 59.0 years in Groups 1 and 2, respectively (P = 0.068). The majority of the sample was in the ASA2 category (46.2% vs. 66.7%, P = 0.341); Ca19.9 levels were higher in Group 1 than in Group 2 (25.7 vs. 13.7, P = 0.027); preoperative Hb was lower in Group 1 than in Group 2 (10.9 g/dL vs. 12.2 g/dL, P = 0.043); the most commonly performed surgery was the McKeown procedure (69.2% vs. 66.7%, P = 0.492); an intraoperative feeding jejunostomy was placed only in Group 2; the operation time was similar between the groups (338.5 min vs. 340 min, P = 0.916); and the distribution of tumor localizations was similar between the groups (P = 0.407). In terms of tumor histology, squamous cell carcinoma (SCC) was the most common tumor type in the two groups (84.6% vs. 80%, P = 0.636); the tumor diameter was similar between the groups (14.9 vs. 18.1, P = 0.652); the number of removed lymph nodes was similar between the groups (24.9 vs. 22.5, P = 0.419); and the number of metastatic lymph nodes was higher in Group 2 (0.08 vs. 1.07, P = 0.27). One patient in Group 2 underwent repeat surgery due to suspected ischemic anastomosis; the distribution of postoperative complications according to the Clavien-Dindo classification system was similar in the two groups (P = 0.650); there was no early mortality within the first 30 days in either group; one patient in Group 2 was re-admitted within 90 days of discharge with decreased oral intake; the length of hospital stay was shorter in Group 1 (9 days vs. 16.5 days, P = 0.006); and the patients in Group 2 more often received neoadjuvant therapy in proportion to the disease stage (15.4% vs. 60%, P = 0.016).

CONCLUSION

Robotic procedures can be safely performed in esophageal cancers with complication rates and oncological radicality similar to those of other minimally invasive techniques.

Impact of thoracic duct resection during radical esophagectomy on oncological and survival outcomes: Systematic review

Practice is variable in the inclusion or exclusion of the thoracic duct (TD) as part of the resected specimen and associated lymphadenectomy in radical esophagectomy for esophageal cancer. While some surgeons believe that the removal of TD-associated nodes may improve radicality and survival, others suggest this represents systemic disease and resection may increase morbidity without survival benefit. A systematic review was performed up to March 2023 using the search terms 'esoph∗' AND 'thoracic duct' for relevant articles which compared thoracic duct preservation (TDP) to resection (TDR) in esophagectomy for esophageal cancer. Included studies were required to report relevant oncological outcomes including at least one of overall survival (OS), disease free survival (DFS) and nodal yield. Seven cohort studies were included in data synthesis, including data for 5926 patients. None of the reported studies were randomised controlled trials. All studies originated from Japan or South Korea with almost exclusively squamous cell-type cancer. Nodal yield was higher in TDR groups. TDR was equivalent or inferior to TDP with reference to clinical outcomes (length of stay, morbidity, mortality). A single study reported increased OS in the TDR group while the remaining studies reported no significant difference. Overall study quality was moderate to poor. While an increased nodal yield may be associated with TDR, this may also be associated with higher morbidity, and currently available data does not suggest any survival benefit.

Reducing the Risks of Esophagectomies: A Retrospective Comparison of Hybrid versus Full-Robotic-Assisted Minimally Invasive Esophagectomy (RAMIE) Approaches

This retrospective analysis aimed to assess and compare the short-term perioperative outcomes and morbidity of hybrid and full-Robotic-Assisted Minimally Invasive Esophagectomy (RAMIE) surgical techniques. A total of 168 robotic-assisted Ivor Lewis esophagectomy procedures performed at Muenster University Hospital were included in the study, with 63 cases in the hybrid group and 105 cases in the full-robotic group. Demographic factors, comorbidities, and tumor stages showed no significant differences between the two groups. However, the full-RAMIE technique demonstrated superiority in terms of overall operative time, postoperative pain levels, and patient morphine consumption. Additionally, the full-RAMIE group exhibited better perioperative outcomes, with significantly shorter ICU stays and fewer occurrences of pneumonias and severe complications. While there was a trend favoring the full-RAMIE technique in terms of severe postoperative complications and anastomotic insufficiencies, further research is required to establish it as the gold standard surgical technique for Ivor Lewis esophagectomy.

Safety and feasibility of three-dimensional McKeown minimally invasive esophagectomy

BACKGROUND

To compare the perioperative outcomes from McKeown minimally invasive esophagectomy (MIE) when performed in three-dimensional versus two-dimensional visualization system, and investigate the learning curve of a single surgeon who implemented three-dimensional McKeown MIE.

METHODS

A total of 335 consecutive cases (three-dimensional or two-dimensional) were identified. Perioperative clinical parameters were compared and cumulative sum learning curve was plotted. Propensity score matching was used to reduce selection bias from confounding factors.

RESULTS

Patients in three-dimensional group were associated with more chronic obstructive pulmonary disease (23.9% vs 3.0%, p < 0.01). After propensity score matching (108 matched patients in each groups), this finding was no longer statistically significant. Comparing to two-dimensional group, significant improvement in total retrieved lymph nodes (28 vs 33, p = 0.003) was observed in three-dimensional group. In addition, more lymph nodes around the right recurrent laryngeal nerve were harvested in three-dimensional group than that in two-dimensional group (p = 0.045). However, there were no significantly differences were found between the two groups in terms of other intraoperative parameters (e.g., operative time) and postoperative relevant outcomes (e.g., lung infection). Furthermore, the change point in the cumulative sum learning curves for intraoperative blood loss and thoracic procedure time was 33 procedures, respectively.

CONCLUSION

Three-dimensional visualization system appears to be superior in performing lymphadenectomy during McKeown MIE to that of a two-dimensional technique. For surgeons proficient in performing two-dimensional McKeown MIE, the learning curve for a three-dimensional procedure appears to begin near proficiency after more than 33 cases.

Analysis of training pathway to reach expert performance levels based on proficiency-based progression in robotic-assisted minimally invasive esophagectomy (RAMIE)

BACKGROUND

Robotic-assisted minimally invasive esophagectomy (RAMIE) was first introduced in 2003 and has since then shown to significantly improve the postoperative course. Previous studies have shown that a structured training pathway based on proficiency-based progression using individual skill levels as measures of reach of competence can enhance surgical performance. The aim of this study was to evaluate and help understand our pathway to reach surgical expert levels using a proficiency-based approach introducing RAMIE at our German high-volume center.

METHODS

All patients undergoing RAMIE performed by two experienced surgeons for esophageal cancer since the introduction of the robotic technique in 2017 was included in this analysis. Intraoperative outcomes and postoperative outcomes were included in the analysis. The cumulative sum method was used to analyze how many cases are needed to reach expert levels for different performance characteristics and skill sets during robotic-assisted minimally invasive esophagectomy.

RESULTS

From 06/2017 to 03/2022, a total of 154 patients underwent RAMIE at our facility and were included in the analysis. An advancement in performance level was observed for total operating time after 70 cases and for thoracic operative time after 79 cases. Lymph node yield showed an increase up until case 60 in the CUSUM analysis. Length of hospital stay stabilized after case 55. The CCI score inflection point was at case 55 in both CUSUM and regression analyses. Anastomotic leak rate stabilized at case 38 and showed another inflection point after case 83.

CONCLUSION

Our data and analysis showed the progression from proficient to expert performance levels during the implementation of RAMIE at a European high-volume center. Further analysis of surgeons, especially with a different training status has yet to reveal if the caseloads found in this study are universally applicable. However, skill acquisition and respective measures of such are diverse and as a great range of number of cases was observed, we believe that the learning curve and ascent in performance levels cannot be defined by one parameter alone.

Robotic Versus Conventional Minimally Invasive Esophagectomy for Esophageal Cancer: A Meta-analysis

OBJECTIVES

To give a comprehensive review of the literature comparing perioperative outcomes and long-term survival with robotic-assisted minimally invasive esophagectomy (RAMIE) versus minimally invasive esophagectomy (MIE) for esophageal cancer.

BACKGROUND

Curative minimally invasive surgical treatment for esophageal cancer includes RAMIE and conventional MIE. It remains controversial whether RAMIE is comparable to MIE.

METHODS

This review was registered at the International Prospective Register of Systematic Reviews (CRD42021260963). A systematic search of databases was conducted. Perioperative outcomes and long-term survival were analyzed and subgroup analysis was conducted. Cumulative meta-analysis was performed to track therapeutic effectiveness.

RESULTS

Eighteen studies were included and a total of 2932 patients (92.88% squamous cell carcinoma, 29.83% neoadjuvant therapy, and 38.93% stage III-IV), 1418 underwent RAMIE and 1514 underwent MIE, were analyzed. The number of total lymph nodes (LNs) [23.35 (95% CI: 21.41-25.29) vs 21.98 (95% CI: 20.31-23.65); mean difference (MD) = 1.18; 95% CI: 0.06-2.30; P =0.04], abdominal LNs [9.05 (95% CI: 8.16-9.94) vs 7.75 (95% CI: 6.62-8.88); MD = 1.04; 95% CI: 0.19-1.89; P =0.02] and LNs along the left recurrent laryngeal nerve [1.74 (95% CI: 1.04-2.43) vs 1.34 (95% CI: 0.32-2.35); MD = 0.22; 95% CI: 0.09-0.35; P <0.001] were significantly higher in the RAMIE group. RAMIE is associated with a lower incidence of pneumonia [9.61% (95% CI: 7.38%-11.84%) vs 14.74% (95% CI: 11.62%-18.15%); odds ratio = 0.73; 95% CI: 0.58-0.93; P =0.01]. Meanwhile, other perioperative outcomes, such as operative time, blood loss, length of hospital stay, 30/90-day mortality, and R0 resection, showed no significant difference between the two groups. Regarding long-term survival, the 3-year overall survival was similar in the two groups, whereas patients undergoing RAMIE had a higher rate of 3-year disease-free survival compared with the MIE group [77.98% (95% CI: 72.77%-82.43%) vs 70.65% (95% CI: 63.87%-77.00%); odds ratio = 1.42; 95% CI: 1.11-1.83; P =0.006]. A cumulative meta-analysis conducted for each outcome demonstrated relatively stable effects in the two groups. Analyses of each subgroup showed similar overall outcomes.

CONCLUSIONS

RAMIE is a safe and feasible alternative to MIE in the treatment of resectable esophageal cancer with comparable perioperative outcomes and seems to indicate a possible superiority in LNs dissection in the abdominal cavity, and LNs dissected along the left recurrent laryngeal nerve and 3-year disease-free survival in particular in esophageal squamous cell carcinoma. Further randomized studies are needed to better evaluate the long-term benefits of RAMIE compared with MIE.

Essential updates 2020/2021: Recent topics in surgery and perioperative therapy for esophageal cancer

In this review, we focused on four topics, namely, minimally invasive esophagectomy (MIE), robot-assisted minimally invasive esophagectomy (RAMIE), conversion and salvage surgery, and neoadjuvant and adjuvant therapy, based on notable reports published in the years 2020 and 2021. It seems that while the short-term outcomes of minimally invasive Ivor Lewis esophagectomy (MIE-IL) were better than those of open Ivor Lewis esophagectomy (OE-IL), there were no significant differences in the long-term outcomes between MIE-IL and OE-IL. Similarly, the short-term outcomes of minimally invasive McKeown esophagectomy (MIE-MK) were better than those of open McKeown esophagectomy (OE-MK), while there were no significant differences in the long-term outcomes between MIE-MK and OE-MK. Furthermore, the short-term outcomes of robot-assisted minimally invasive Ivor Lewis esophagectomy (RAMIE-IL) were superior to those of completely minimally invasive Ivor Lewis esophagectomy (CMIE-IL). On the other hand, there were advantages and disadvantages in relation to the short-term outcomes of robot-assisted minimally invasive McKeown esophagectomy (RAMIE-MK) as compared with completely minimally invasive McKeown esophagectomy (CMIE-MK). However, there were no significant differences in the long-term outcomes between RAMIE-MK and CMIE-MK. Further research is needed to evaluate of short-term and long-term outcomes of transmediastinal esophagectomy with and without robotic assistance. Both induction chemotherapy and induction chemoradiotherapy appear to be promising to secure a higher rate of conversion surgery. Neoadjuvant chemoimmunotherapy and chemoimmunoradiotherapy have shown promising results and are expected as new powerful therapies.

Introducing robotic oesophagectomy into an Australian practice: an assessment of the early procedural outcomes and learning curve

BACKGROUND

Robotic oesophagectomy (RAMIO) is a novel procedure in Australia and New Zealand. We aimed to report the early operative and clinical outcomes achieved during the introduction of RAMIO into the practice of a single Australian surgeon and benchmark these against outcomes of patients receiving conventional minimally invasive oesophagectomy (MIO) by the same surgeon.

METHODS

Data on all patients undergoing RAMIO, performed by a single high-volume Australian surgeon, were collected from a prospectively maintained database. Operative, clinical and surgical quality outcomes were benchmarked on a univariable basis against those of patients receiving MIO. Learning curves were computed using quadratic and linear regression of operating times on case-numbers and compared using Cox regression modelling.

RESULTS

290 patients (237 MIO, 53 RAMIO (47% Ivor-Lewis, 53% McKeon oesophagectomy)) were included. Compared with MIO, the median thoracic operating time was 20 min longer for RAMIO (P = 0.03). Following RAMIO, there was less blood loss (P < 0.01) and a shorter length of stay (P < 0.01).There were no differences in morbidity and quality of surgery following RAMIO compared with MIO. There were no deaths following RAMIO. Having progressed from MIO, the operating times for RAMIO improved after 22 cases compared with MIO (110 cases) (HR 0.70 (0.51-0.93), P = 0.01).

CONCLUSION

With careful implementation, RAMIO may be safely performed within the Australian setting and is associated with a modest increase in procedure duration, but less blood loss and shorter length of stay compared with conventional MIO.

Impact of neoadjuvant FLOT treatment of advanced gastric and gastroesophageal junction cancer following surgical therapy

Introduction

Therapeutic treatment for advanced-stage (T2–T4) gastroesophageal junction (GEJ) and gastric cancer involves neoadjuvant chemotherapy with subsequent surgical intervention.

Method

Neoadjuvant oncological treatment for GEJ and gastric cancer previously consisted of the intravenous administration of epirubicin, cisplatin and fluorouracil (ECF) or epirubicin, cisplatin and capecitabine (ECX) combination (Group 1). The new protocol (FLOT, F: 5-FU, L: leucovorin, O: oxaliplatin, T: docetaxel), included patients with resectable GEJ and gastric cancer who had a clinical stage cT2 or higher nodal positive cN+ disease (Group 2). Between 31 December 2008 and 31 October 2022, the effect of different oncological protocols in terms of surgical outcomes in cases of T2–T4 tumours were retrospectively evaluated. Results of randomly assigned patients from the earlier ECF/ECX protocol (n = 36) (Group 1) and the new FLOT protocol (n = 52) (Group 2) were compared. Effect of different neoadjuvant therapies on tumour regression, types of possible side effects, type of surgery, and oncological radicality of surgical procedures were analysed.

Results

When comparing the two groups, we found that in case of the FLOT neoadjuvant chemotherapy (Group 2, n = 52), complete regression was achieved in 13.95% of patients, whereas in the case of ECF/ECX (Group 1, n = 36), complete regression occurred in only 9.10% of patients. Furthermore, in the FLOT group, the mean number of lymph nodes removed was slightly higher (24.69 vs. 20.13 in the ECF/ECX group). In terms of the safety resection margin (proximal), no significant difference was found between the two treatment groups. Nausea and vomiting were the most common side effects. The occurrence of diarrhea was significantly higher in the FLOT group (p = 0.006). Leukopenia and nausea occurred more commonly with the old protocol (Group 1). The rate of neutropenia was lower following FLOT treatment (p = 0.294), with the lack of grade II and III cases. Anaemia occured at a significantly higher rate (p = 0.036) after the ECF/ECX protocol.

Conclusions

As a result of the FLOT neoadjuvant oncological protocol for advanced gastro-esophageal junction and gastric cancer, the rate of complete tumour regression increased significantly. The rate of side effects was also appreciably lower following the FLOT protocol. These results strongly suggest a significant advantage of the FLOT neoadjuvant treatment used before surgery.

Robotic Esophagectomy Trends and Early Surgical Outcomes: The US Experience

BACKGROUND

Recent esophagectomy trends were evaluated to describe the shift in surgical approach and outcomes using The Society of Thoracic Surgeons General Thoracic Surgery Database.

METHODS

All patients who underwent an esophagectomy with gastric conduit from 2015 to 2019 were identified and analyzed according to original intended approach. After performing volume trend analysis of patients, operative outcomes were evaluated.

RESULTS

Among 10,607 patients, esophagectomy was open in 5763 (54.3%), minimally invasive (MIE) in 3524 (33.2%), and robotic (RAMIE) in 1320 (12.4%). Within 5 years, MIE and RAMIE combined rose to majority approach (open from 58% to 42% of annual volume). While MIE and RAMIE were associated with higher rates of anastomotic leak, loss of conduit, pulmonary embolus, and reoperation, R0 resection and harvested number of lymph nodes exceeded those in open approaches. Operative mortality did not differ by approach (3.21% open vs 2.72% MIE vs 2.50% RAMIE; P = .2329). On multivariable analysis, RAMIE was independently associated with higher rate of anastomotic leak compared to open (adjusted odds ratio 1.53, 95% CI 1.14-2.04), while both MIE and RAMIE had lower mean length of stay. Propensity matching of 1320 pairs found a higher risk of anastomotic leak requiring surgery for RAMIE compared with MIE (adjusted odds ratio 1.39, 95% CI 1.01-1.92).

CONCLUSIONS

In less than a decade, the dominant surgical approach in The Society of Thoracic Surgeons General Thoracic Surgery Database has become minimally invasive (RAMIE and MIE). While anastomotic leak and reoperation, more common in RAMIE, require a technical solution, these complications have not raised operative mortality. Further studies are needed to address long-term results and oncologic outcome.

Robotic versus thoraco-laparoscopic minimally invasive Ivor Lewis esophagectomy, a matched-pair single-center cohort analysis

Minimally invasive esophagectomy (MIE) is becoming more widespread with a documented improvement in postoperative morbidity based on level I evidence. However, there is a lack of consensus regarding the optimal MIE approach, conventional thoracoscopy/laparoscopy vs robotics as well as the ideal anastomotic technique. All patients who underwent MIE via an Ivor Lewis approach with a side-to-side stapled anastomosis were included. The thoracoscopy-laparoscopy (TL) group was compared to the robotic group with respect to perioperative outcomes using the entire cohorts and after 1:1 propensity score matching. Comparisons were made using the Mann-Whitney U and Fisher's exact tests. Between July 2013 and November 2020, 72 TL and 67 robotic Ivor Lewis MIE were performed. After comparing the two unadjusted cohorts and 51 propensity matched pairs, there was a decrease in Clavien-Dindo Grade 2 or above complications in the robotic vs TL group (59.7% vs 41.8% [P = 0.042], (62.7% vs 39.2% [P = 0.029]), respectively. In both analyses, there was a reduction in hospital length of stay (median of 8 vs 7 days, P < 0.001) and a trend toward less anastomotic leaks in the robotic group (Unadjusted: 12.5 vs 3% [P = 0.057], Propensity-matched analysis: 13.7% vs 3.9% [P = 0.16]), respectively. A clinically significant decrease in overall morbidity, cardiac complications and hospital length of stay was observed in the robotic Ivor Lewis cohort when compared with the TL group at a high volume MIE program. Side-to-side stapled thoracic anastomoses utilizing a robotic platform provides the best outcomes in this single institution experience.

Robot-assisted Ivor Lewis Esophagectomy (RAILE): A review of surgical techniques and clinical outcomes

In the past 20 years, robotic system has gradually found a place in esophagectomy which is a demanding procedure in the deep and narrow thoracic cavity containing crucial functional structures. Ivor Lewis esophagectomy (ILE) is a mainstream surgery type for esophagectomy and is widely accepted for its capability in lymphadenectomy and relatively mitigated trauma. As a minimally invasive technique, robot-assisted Ivor Lewis esophagectomy (RAILE) has been frequently compared with the video-assisted procedure and the traditional open procedure. However, high-quality evidence elucidating the advantages and drawbacks of RAILE is still lacking. In this article, we will review the surgical techniques, both short and long-term outcomes, the learning curve, and explicate the current progress and clinical efficacy of RAILE.

Worldwide Techniques and Outcomes in Robot-assisted Minimally Invasive Esophagectomy (RAMIE): Results From the Multicenter International Registry

OBJECTIVE

This international multicenter study by the Upper GI International Robotic Association aimed to gain insight in current techniques and outcomes of RAMIE worldwide.

BACKGROUND

Current evidence for RAMIE originates from single-center studies, which may not be generalizable to the international multicenter experience.

METHODS

Twenty centers from Europe, Asia, North-America, and South-America participated from 2016 to 2019. Main endpoints included the surgical techniques, clinical outcomes, and early oncological results of ramie.

RESULTS

A total of 856 patients undergoing transthoracic RAMIE were included. Robotic surgery was applied for both the thoracic and abdominal phase (45%), only the thoracic phase (49%), or only the abdominal phase (6%). In most cases, the mediastinal lymphadenectomy included the low paraesophageal nodes (n=815, 95%), subcarinal nodes (n = 774, 90%), and paratracheal nodes (n = 537, 63%). When paratracheal lymphadenectomy was performed during an Ivor Lewis or a McKeown RAMIE procedure, recurrent laryngeal nerve injury occurred in 3% and 11% of patients, respectively. Circular stapled (52%), hand-sewn (30%), and linear stapled (18%) anastomotic techniques were used. In Ivor Lewis RAMIE, robot-assisted hand-sewing showed the highest anastomotic leakage rate (33%), while lower rates were observed with circular stapling (17%) and linear stapling (15%). In McKeown RAMIE, a hand-sewn anastomotic technique showed the highest leakage rate (27%), followed by linear stapling (18%) and circular stapling (6%).

CONCLUSION

This study is the first to provide an overview of the current techniques and outcomes of transthoracic RAMIE worldwide. Although these results indicate high quality of the procedure, the optimal approach should be further defined.

Robot-assisted transthoracic hybrid esophagectomy versus open and laparoscopic hybrid esophagectomy: propensity score matched analysis of short-term outcome

PURPOSE

Minimally invasive en-bloc esophagectomy is associated with a reduction of postoperative morbidity. This was demonstrated for both total minimally invasive and hybrid esophagectomy. However, little is known about any benefits of robotic assistance compared to the conventional minimally invasive technique, especially in hybrid procedures.

METHODS

For this retrospective study, all consecutive patients who had undergone elective esophagectomy with circular stapled intrathoracic anastomosis using the open and the minimally invasive hybrid technique at the University Hospital Magdeburg, from January 2010 to March 2021 were considered for analysis.

RESULTS

In total, 137 patients (60.4%) had undergone open esophagectomy. In 45 patients (19.8%), the laparoscopic hybrid technique and in 45 patients (19.8%), the robot-assisted hybrid technique were applied. In propensity score matching analysis comparing the open with the robotic hybrid technique, significant differences were found in favor of the robotic technique (postoperative morbidity, p < 0.01; hospital length of stay, p < 0.01; number of lymph nodes retrieved, p = 0.048). In propensity score matching analysis comparing the laparoscopic with the robotic hybrid technique, a significant reduction of the rate of postoperative delayed gastric emptying (p = 0.02) was found for patients who had undergone robotic esophagectomy. However, the operation time was significantly longer (p < 0.01).

CONCLUSIONS

En-bloc esophagectomy using the robotic hybrid technique is associated with a significant reduction of postoperative morbidity and of the hospital length of stay when compared to the open approach. However, when compared to the laparoscopic hybrid technique, only few advantages could be demonstrated.

Robot-assisted esophagectomy may improve perioperative outcome in patients with esophageal cancer – a single-center experience

Background

Although the introduction of minimally invasive surgical techniques has improved surgical outcomes in recent decades, esophagectomy for esophageal cancer is still associated with severe complications and a high mortality rate. Robot-assisted surgery is already established in certain fields and robot-assisted esophagectomy may be a possible alternative to the standard minimally invasive esophagectomy. The goal of this study was to investigate whether robot assistance in esophagectomy can improve patient outcome while maintaining good oncological control.

Material and methods

Data of all patients who underwent minimally invasive esophagectomy between January 2018 and November 2021 at University Hospital Mannheim was collected retrospectively. Patients were divided into two cohorts according to operative technique (standard minimally invasive (MIE) vs. robot-assisted esophagectomy (RAMIE), and their outcomes compared. In a separate analysis, patients were propensity score matched according to age, gender and histological diagnosis, leading to 20 matching pairs.

Results

95 patients were included in this study. Of those, 71 patients underwent robot-assisted esophagectomy and 24 patients underwent standard minimally invasive esophagectomy. Robot-assisted esophagectomy showed a lower incidence of general postoperative complications (52.1% vs. 79.2%, p=0.0198), surgical complications (42.3% vs. 75.0%, p=0.0055), a lower rate of anastomotic leakage (21.1% vs. 50.0%, p=0.0067), a lower Comprehensive Complication Index (median of 20.9 vs. 38.6, p=0.0065) as well as a shorter duration of hospital stay (median of 15 vs. 26 days, p=0.0012) and stay in the intensive care unit (median of 4 vs. 7 days, p=0.028) than standard minimally invasive surgery. After additionally matching RAMIE and MIE patients according to age, gender and diagnosis, we found significant improvement in the RAMIE group compared to the MIE group regarding the Comprehensive Complication Index (median of 20.9 vs. 38.6, p=0.0276), anastomotic leakage (20% vs. 55%, p=0.0484) and severe toxicity during neoadjuvant treatment (0 patients vs. 9 patients, p=0.005).

Conclusion

Robot-assisted surgery can significantly improve outcomes for patients with esophageal cancer. It may lead to a shorter hospital stay as well as lower rates of complications, including anastomotic leakage.

End to side circular stapled anastomosis during robotic-assisted Ivor Lewis minimally invasive esophagectomy (RAMIE)

Robotic-assisted minimally invasive esophagectomy (RAMIE) represents an established approach for the treatment of esophageal cancer. Aim of this study is to evaluate the feasibility and safety of our technique for performing the intrathoracic anastomosis during RAMIE.All the procedures were performed by the same surgeon using the same technique for performing the intrathoracic anastomosis. Intraoperative and postoperative outcomes were recorded. Postoperative complications were classified according to the Esophagectomy Complications Consensus Group (ECCG); the primary outcome was the evaluation of the feasibility and safety of our technique. From 2016 to 2021, 204 patients underwent Ivor Lewis RAMIE at our Center. Two patients (0.9%) were converted during the thoracic phase. The anastomosis was completed in all the other patients forming complete anastomotic rings. The median duration for the robotic-assisted thoracoscopic phase was 224 minutes. Twenty-two of the RAMIE-Ivor Lewis patients had an anastomotic leakage (10.3%). The overall 90-day postoperative mortality was 1.9%. The procedure resulted to be feasible and safe in our cohort of patients.

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

Simple Summary

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

Abstract

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

Selection of minimally invasive surgical approaches for treating esophageal cancer

Minimally invasive esophagectomy has gradually been accepted as an active treatment option for surgery of esophageal cancer. However, there is no consensus about how to perform the procedures in the thoracic and abdominal phase including anastomosis in the neck (McKeown) or chest (Ivor Lewis), VATS, robotic‐assisted or reduced port approaches or various endoscopic abrasion techniques. Further studies to investigate the roles of these novel techniques are required to treat the various patient populations.

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.

Robot-assisted minimally invasive esophagectomy (RAMIE) vs. hybrid minimally invasive esophagectomy: propensity score matched short-term outcome analysis of a European high-volume center

INTRODUCTION

Transthoracic esophagectomy is a highly complex and sophisticated procedure with high morbidity rates and a significant mortality. Surgical access has consistently become less invasive, transitioning from open esophagectomy to hybrid esophagectomy (HE) then to totally minimally invasive esophagectomy (MIE), and most recently to robot-assisted minimally invasive esophagectomy (RAMIE), with each step demonstrating improved patient outcomes. Aim of this study with more than 600 patients is to complete a propensity-score matched comparison of postoperative short-term outcomes after highly standardized RAMIE vs. HE in a European high volume center.

PATIENTS AND METHODS

Six hundred and eleven patients that underwent transthoracic Ivor-Lewis esophagectomy for esophageal cancer between May 2016 and May 2021 were included in the study. In January 2019, we implemented an updated robotic standardized anastomotic technique using a circular stapler and ICG (indocyanine green) for RAMIE cases. Data were retrospectively analyzed from a prospectively maintained IRB-approved database. Outcomes of patients undergoing standardized RAMIE from January 2019 to May 2021 were compared to our overall cohort from May 2016-April 2021 (HE) after a propensity-score matching analysis was performed.

RESULTS

Six hundred and eleven patients were analyzed. 107 patients underwent RAMIE. Of these, a total of 76 patients underwent a robotic thoracic reconstruction using the updated standardized circular stapled anastomosis (RAMIE group). A total of 535 patients underwent HE (Hybrid group). Seventy patients were propensity-score matched in each group and analysis revealed no statistically significant differences in baseline characteristics. RAMIE patients had a significantly shorter ICU stay (p = 0.0218). Significantly more patients had no postoperative complications (Clavien Dindo 0) in the RAMIE group [47.1% vs. 27.1% in the HE group (p = 0.0225)]. No difference was seen in lymph node yield and R0 resection rates. Anastomotic leakage rates when matched were 14.3% in the hybrid group vs. 4.3% in the RAMIE group (p = 0.07).

CONCLUSION

Our analysis confirms the safety and feasibility of RAMIE and HE in a large cohort after propensity score matching. A regular postoperative course (Clavien-Dindo 0) and a shorter ICU stay were seen significantly more often after RAMIE compared to HE. Furthermore it shows that both procedures provide excellent short-term oncologic outcomes, regarding lymph node harvest and R0 resection rates. A randomized controlled trial comparing RAMIE and HE is still pending and will hopefully contribute to ongoing discussions.

Indocyanine green (ICG) fluorescence imaging for prevention of anastomotic leak in totally minimally invasive Ivor Lewis esophagectomy: a systematic review and meta-analysis

BACKGROUND

Indocyanine green (ICG) fluorescence imaging is an emerging technology that might help decreasing anastomotic leakage (AL) rates. The aim of this study was to determine the usefulness of ICG fluorescence imaging for the prevention of AL after minimally invasive esophagectomy with intrathoracic anastomosis.

METHODS

A systematic literature review of the MEDLINE and Cochrane databases was performed to identify all articles on totally minimally invasive Ivor Lewis esophagectomy. Studies were then divided into two groups based on the use or not of ICG for perfusion assessment. Primary outcome was anastomotic leak. Secondary outcomes included operative time, ICG-related adverse reactions, and mortality rate. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for main outcomes.

RESULTS

A total of 3,171 patients were included for analysis: 381 (12%) with intraoperative ICG fluorescence imaging and 2,790 (88%) without ICG. Mean patients' age and proportion of males were similar between groups. Mean operative time was also similar between both groups (ICG: 354.8 vs. No-ICG: 354.1 minutes, P = 0.52). Mean ICG dose was 12 mg (5-21 mg). No ICG-related adverse reactions were reported. AL rate was 9% (95% CI, 5-17%) and 9% (95% CI, 7-12%) in the ICG and No-ICG groups, respectively. The risk of AL was similar between groups (odds ratio 0.85, 95% CI 0.53-1.28, P = 0.45). Mortality was 3% (95% CI, 1-9%) in patients with ICG and 2% (95% CI, 2-3%) in those without ICG. Median length of hospital stay was also similar between groups (ICG: 13.6 vs. No-ICG: 11.2 days, P = 0.29).

CONCLUSION

The use of ICG fluorescence imaging for perfusion assessment does not seem to reduce AL rates in patients undergoing minimally invasive esophagectomy with intrathoracic anastomosis.

Short-term outcomes of robot-assisted minimally invasive esophagectomy with extended lymphadenectomy for esophageal cancer compared with video-assisted minimally invasive esophagectomy: A single-center retrospective study

BACKGROUND

The safety and feasibility of robot-assisted minimally invasive esophagectomy (RAMIE) remain unclear. The aim of this study was to compare the short-term outcomes of RAMIE with extended lymphadenectomy and conventional minimally invasive esophagectomy (MIE) in order to investigate the safety and feasibility of RAMIE.

METHODS

A retrospective analysis of 87 patients who underwent minimally invasive esophagectomy at our institution between April 2018 and March 2020 was made, assigning 22 in the RAMIE group and 65 in the MIE group. Short-term clinical outcomes and clinical baseline data were compared.

RESULTS

The baseline characteristics were comparable. No significant difference in median thoracic phase blood loss and median number of dissected mediastinal lymph nodes were observed. The median operative time of thoracic approach was significantly longer in the RAMIE group than the MIE group (305 minutes [221-397] vs 227 minutes [133-365], P < .0001). With respect to postoperative complications such as recurrent laryngeal nerve paralysis (Clavien-Dindo ≥ grade II) (RAMIE 4.6% vs MIE 17%, P = .11) and postoperative pneumonia (Clavien-Dindo ≥ grade III) (RAMIE 9% vs MIE 23%, P = .13), no significant difference was observed. The patients in the RAMIE group had a better postoperative swallowing function (P = .023) and were able to start oral food intake significantly earlier (P = .007). The median hospital stay was significantly shorter in the RAMIE group than in the MIE (23 days vs 35 days, P = .009).

CONCLUSIONS

RAMIE with extended lymphadenectomy was safe and feasible for esophageal cancer and resulted in improved postoperative swallowing function and shorter postoperative hospital stay.

Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis

BACKGROUND

A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE).

METHODS

A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome.

RESULTS

A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively.

CONCLUSIONS

Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.

Minimally invasive Ivor Lewis esophagectomy: Robot-assisted versus laparoscopic-thoracoscopic technique. Systematic review and meta-analysis

BACKGROUND

Evidence comparing conventional minimally invasive esophagectomy (CMIE) via laparoscopy and thoracoscopy with robot-assisted minimally invasive esophagectomy (RAMIE) is scarce. The aim of this meta-analysis was to compare surgical outcomes after CMIE and RAMIE with an intrathoracic anastomosis.

METHODS

A systematic literature search was performed to identify original articles analyzing outcomes after CMIE and RAMIE. Main surgical outcomes included operative time, intraoperative blood loss, anastomotic leak rates, pneumonia, overall morbidity, length of stay (LOS), and 30-day mortality. Oncologic outcomes included lymph node yield and R0 resections rates. A meta-analysis of proportions and linear regression models were used to assess the effect of each procedure on the different outcomes.

RESULTS

A total of 6,249 patients were included for analysis; 5,275 (84%) underwent CMIE and 974 (16%) RAMIE. Robotic esophagectomy had longer operative time and less intraoperative blood loss. Anastomotic leakage rates were similar with both approaches. Patients undergoing RAMIE had significantly lower rates of postoperative pneumonia (OR 0.46, 95% CI 0.35-0.61, P < .0001) and overall morbidity (OR 0.67, 95% CI 0.58-0.79, P < .0001). Median LOS was similar in both procedures (RAMIE: 12.1 versus CMIE: 11.9 days, P = .64). Similar mortality rates were found after RAMIE and CMIE (OR 0.69, 95% CI 0.34-1.38, P = .29). Lymph node yield was similar in both procedures, but RAMIE was associated with higher rates of R0 resection (OR 2.84, 95% CI 1.53-5.26, P < .001).

CONCLUSION

Patients undergoing robotic esophagectomy have less intraoperative blood loss, lower rates of postoperative pneumonia, reduced overall morbidity, and higher rates of R0 resections, as compared with those undergoing a laparoscopic-thoracoscopic esophageal resection.

Surgical Therapy of Esophageal Adenocarcinoma-Current Standards and Future Perspectives

Transthoracic esophagectomy is currently the predominant curative treatment option for resectable esophageal adenocarcinoma. The majority of carcinomas present as locally advanced tumors requiring multimodal strategies with either neoadjuvant chemoradiotherapy or perioperative chemotherapy alone. Minimally invasive, including robotic, techniques are increasingly applied with a broad spectrum of technical variations existing for the oncological resection as well as gastric reconstruction. At the present, intrathoracic esophagogastrostomy is the preferred technique of reconstruction (Ivor Lewis esophagectomy). With standardized surgical procedures, a complete resection of the primary tumor can be achieved in almost 95% of patients. Even in expert centers, postoperative morbidity remains high, with an overall complication rate of 50-60%, whereas 30- and 90-day mortality are reported to be <2% and <6%, respectively. Due to the complexity of transthoracic esophagetomy and its associated morbidity, esophageal surgery is recommended to be performed in specialized centers with an appropriate caseload yet to be defined. In order to reduce postoperative morbidity, the selection of patients, preoperative rehabilitation and postoperative fast-track concepts are feasible strategies of perioperative management. Future directives aim to further centralize esophageal services, to individualize surgical treatment for high-risk patients and to implement intraoperative imaging modalities modifying the oncological extent of resection and facilitating surgical reconstruction.

Comparison of Clinical Outcomes of Robot-Assisted, Video-Assisted, and Open Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-analysis

IMPORTANCE

The utilization of robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer is increasing, despite limited data comparing RAMIE with other surgical approaches.

OBJECTIVE

To evaluate the literature for clinical outcomes of RAMIE compared with video-assisted minimally invasive esophagectomy (VAMIE) and open esophagectomy (OE).

DATA SOURCES

A systematic search of PubMed, Cochrane, Ovid Medline, and Embase databases from January 1, 2013, to May 6, 2020, was performed.

STUDY SELECTION

Studies that compared RAMIE with VAMIE and/or OE for cancer were included.

DATA EXTRACTION AND SYNTHESIS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline, data were extracted by independent reviewers. A random-effects meta-analysis of 9 propensity-matched studies was performed for the RAMIE vs VAMIE comparison only. A narrative synthesis of RAMIE vs VAMIE and OE was performed.

MAIN OUTCOMES AND MEASURES

The outcomes of interest were intraoperative outcomes (ie, estimated blood loss [EBL], operative time, lymph node [LN] harvest), short-term outcomes (anastomotic leak, recurrent laryngeal nerve [RLN] palsy, pulmonary and total complications, and 90-day mortality), and long-term oncologic outcomes.

RESULTS

Overall, 21 studies (2 randomized clinical trials, 11 propensity-matched studies, and 8 unmatched studies) with 9355 patients were included. A meta-analysis was performed with 9 propensity-matched studies comparing RAMIE with VAMIE. The random-effects pooled estimate found an adjusted risk difference (RD) of -0.06 (95% CI, -0.11 to -0.01) favoring fewer pulmonary complications with RAMIE. There was no evidence of differences between RAMIE and VAMIE in LN harvest (mean difference [MD], -1.1 LN; 95% CI, -2.45 to 0.25 LNs), anastomotic leak (RD, 0.0; 95% CI, -0.03 to 0.03), EBL (MD, -6.25 mL; 95% CI, -18.26 to 5.77 mL), RLN palsy (RD, 0.01; 95% CI, -0.08 to 0.10), total complications (RD, 0.05; 95% CI, -0.01 to 0.11), or 90-day mortality (RD, -0.01; 95% CI, -0.02 to 0.0). There was low certainty of evidence that RAMIE was associated with a longer disease-free survival compared with VAMIE. For OE comparisons (data not pooled), RAMIE was associated with a longer operative time, decreased EBL, and less pulmonary and total complications.

CONCLUSIONS AND RELEVANCE

In this study, RAMIE had similar outcomes as VAMIE but was associated with fewer pulmonary complications compared with VAMIE and OE. Studies on long-term functional and cancer outcomes are needed.

Meta-analysis of randomized controlled trials and individual patient data comparing minimally invasive with open oesophagectomy for cancer

BACKGROUND

Minimally invasive oesophagectomy (MIO) for oesophageal cancer may reduce surgical complications compared with open oesophagectomy. MIO is, however, technically challenging and may impair optimal oncological resection. The aim of the present study was to assess if MIO for cancer is beneficial.

METHODS

A systematic literature search in MEDLINE, Web of Science and CENTRAL was performed and randomized controlled trials (RCTs) comparing MIO with open oesophagectomy were included in a meta-analysis. Survival was analysed using individual patient data. Random-effects model was used for pooled estimates of perioperative effects.

RESULTS

Among 3219 articles, six RCTs were identified including 822 patients. Three-year overall survival (56 (95 per cent c.i. 49 to 62) per cent for MIO versus 52 (95 per cent c.i. 44 to 60) per cent for open; P = 0.54) and disease-free survival (54 (95 per cent c.i. 47 to 61) per cent versus 50 (95 per cent c.i. 42 to 58) per cent; P = 0.38) were comparable. Overall complication rate was lower for MIO (odds ratio 0.33 (95 per cent c.i. 0.20 to 0.53); P < 0.010) mainly due to fewer pulmonary complications (OR 0.44 (95 per cent c.i. 0.27 to 0.72); P < 0.010), including pneumonia (OR 0.41 (95 per cent c.i. 0.22 to 0.77); P < 0.010).

CONCLUSION

MIO for cancer is associated with a lower risk of postoperative complications compared with open resection. Overall and disease-free survival are comparable for the two techniques.

LAY SUMMARY

Oesophagectomy for cancer is associated with a high risk of complications. A minimally invasive approach might be less traumatic, leading to fewer complications and may also improve oncological outcome. A meta-analysis of randomized controlled trials comparing minimally invasive to open oesophagectomy was performed. The analysis showed that the minimally invasive approach led to fewer postoperative complications, in particular, fewer pulmonary complications. Survival after surgery was comparable for the two techniques.

Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus minimally invasive esophagectomy for resectable esophageal adenocarcinoma, a randomized controlled trial (ROBOT-2 trial)

BACKGROUND

For patients with esophageal adenocarcinoma or cancer of the gastroesophageal junction, radical esophagectomy with 2-field lymphadenectomy is the cornerstone of the multimodality treatment with curative intent. Both conventional minimally invasive esophagectomy (MIE) and robot assisted minimally invasive esophagectomy (RAMIE) were shown to be superior compared to open transthoracic esophagectomy considering postoperative complications. However, no randomized comparison exists between MIE and RAMIE in the Western World for patients with esophageal adenocarcinoma.

METHODS

This is an investigator-initiated and investigator-driven multicenter randomized controlled parallel-group superiority trial. All adult patients (age ≥ 18 and ≤ 90 years) with histologically proven, surgically resectable (cT1-4a, N0-3, M0) esophageal adenocarcinoma of the intrathoracic esophagus or adenocarcinoma of the gastroesophageal junction and with European Clinical Oncology Group performance status 0, 1 or 2 will be assessed for eligibility and included after obtaining informed consent. Patients (n = 218) with resectable esophageal adenocarcinoma of the intrathoracic esophagus or adenocarcinoma of the gastroesophageal junction are randomized to either RAMIE (n = 109) or MIE (n = 109). The primary outcome of this study is the total number of resected abdominal and mediastinal lymph nodes specified per lymph node station.

CONCLUSION

This is the first randomized controlled trial designed to compare RAMIE to MIE as surgical treatment for resectable esophageal adenocarcinoma or adenocarcinoma of the gastroesophageal junction in the Western World. The hypothesis of the proposed study is that RAMIE will result in a higher abdominal and mediastinal lymph node yield specified per station compared to conventional MIE. Short-term results and the primary endpoint (total number of resected abdominal and mediastinal lymph nodes per lymph node station) will be analyzed and published after discharge of the last randomized patient within this trial.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04306458 . Registered 13th March 2020, https://clinicaltrials.gov/ct2/show/NCT04306458; Date of first enrolment 18.01.2021; Target sample size 218; Recruitment status: Recruiting; Protocol version 2; Issue date 10.03.2020; Rev. 02.02.2021; Authors ET, PCvdS, PPG.

Long-term outcomes of robotic-assisted versus thoraco-laparoscopic McKeown esophagectomy for esophageal cancer: a propensity score-matched study

The long-term outcomes of robotic-assisted McKeown esophagectomy (RAME) compared to thoraco-laparoscopic McKeown esophagectomy (TLME) for the patients with esophageal squamous cell carcinoma (ESCC) remain unclear. The aim of this study was to compare the number of dissected lymph nodes and long-term survival between RAME and TLME using a propensity score-matched (PSM) analysis. A total of 721 patients undergoing minimally invasive McKeown esophagectomy at our department from February 2015 to October 2019 were analyzed, including 310 patients in RAME group and 411 in TLME group. The exact numbers of lymph nodes including those among thoracic and abdominal categories as well as those along the recurrent laryngeal nerve (RLN) were all recorded. PSM analysis was applied to generate matched pairs for further comparison. All patients with R0 resection were followed with a strict follow-up period which range from 1 to 56 months. The effect of lymphadenectomy was compared between all patients in unmatched and matched groups. Long-term outcomes consisting of overall survival (OS), disease-free survival (DFS) and recurrence rate (including regional recurrence rate, systemic recurrence rate and mediastinal lymph nodes recurrence rate) were compared in R0 resection patients. Finally, 292 patients were identified for each cohort after PSM. RAME was found to yield significantly more left RLN lymph nodes (mean: 2.27 ± 0.90 vs. 2.09 ± 0.79; P = 0.011) and more thoracic lymph nodes (mean: 12.60 ± 4.22 vs. 11.83 ± 3.12, P = 0.012) compared with TLME after PSM analysis. There was no significant difference in the OS and DFS between the RAME and TLME group. Besides, total recurrences were recognized in 33 (11.7%) patients in the RAME group and 36 (12.9%) in the TLME group (P = 0.676). The mediastinal lymph nodes recurrence rate in the RAME group was tended to be lower than that in the TLME group (2.5% vs. 5.4%, P = 0.079). Therefore, RAME might be an alternative approach for the treatment of ESCC with more lymph nodes dissected and similar long-term survival outcomes compared to TLME.

Robotic Esophagectomy. A Systematic Review with Meta-Analysis of Clinical Outcomes

Background: Robot-Assisted Minimally Invasive Esophagectomy is demonstrated to be related with a facilitation in thoracoscopic procedure. To give an update on the state of art of robotic esophagectomy for cancr a systematic review with meta-analysis has been performed. Methods: a search of the studies comparing robotic and laparoscopic or open esophagectomy was performed trough the medical libraries, with the search string "robotic and (oesophagus OR esophagus OR esophagectomy OR oesophagectomy)". Outcomes were: postoperative complications rate (anastomotic leakage, bleeding, wound infection, pneumonia, recurrent laryngeal nerves paralysis, chylotorax, mortality), intraoperative outcomes (mean blood loss, operative time and conversion), oncologic outcomes (harvested nodes, R0 resection, recurrence) and recovery outcomes (length of hospital stay). Results: Robotic approach is superior to open surgery in terms of blood loss p = 0.001, wound infection rate, p = 0.002, pneumonia rate, p = 0.030 and mean number of harvested nodes, p < 0.0001 and R0 resection rate, p = 0.043. Similarly, robotic approach is superior to conventional laparoscopy in terms of mean number of harvested nodes, p = 0.001 pneumonia rate, p = 0.003. Conclusions: robotic surgery could be considered superior to both open surgery and conventional laparoscopy. These encouraging results should promote the diffusion of the robotic surgery, with the creation of randomized trials to overcome selection bias.

[Fast-track Rehabilitation after Oesophagectomy]

The multimodal and interprofessional concept of fast-track rehabilitation ("enhanced recovery after surgery", ERAS) is generally applicable to transthoracic oesophagectomy, but is associated with two special features as compared to other oncological procedures. Due to the high comorbidity of oesophageal cancer patients, fast-track pathways have to be considered as one component of perioperative management and cannot be separated from prehabilitation with preoperative conditioning of single organ dysfunctions. Since gastric reconstruction causes a high prevalence of delayed gastric conduit emptying (DGCE), early and sufficient postoperative oral feeding is not easily feasible. There is currently no generally accepted algorithm for the postoperative nutritional management as well as for the prophylaxis/treatment of DGCE. Fast-track prehabilitation does not influence the mortality rate in specialised centres. At present, it is not clear whether a fast-track pathway helps to reduce postoperative morbidity. After modified fast-track rehabilitation, hospital discharge is possible from the 8th postoperative day.

Lower local recurrence rate after robot-assisted thoracoscopic esophagectomy than conventional thoracoscopic surgery for esophageal cancer

The oncological advantages of robot-assisted thoracoscopic esophagectomy (RATE) over conventional thoracoscopic esophagectomy (TE) for thoracic esophageal cancer have yet to be verified. In this study, we retrospectively analyzed clinical data to compare the incidences of recurrence within the surgical field after RATE and TE as an indicator of local oncological control. Among 121 consecutive patients with thoracic esophageal or esophagogastric junction cancers for which thoracoscopic surgery was indicated, 51 were treated with RATE while 70 received TE. The number of lymph nodes dissected from the mediastinum, duration of the thoracic portion of the surgery, and morbidity due to postoperative complications did not differ between the two groups. However, the rate of overall local recurrence within the surgical field was significantly (P = 0.039) higher in the TE (9%) than the RATE (0%) group. Lymph node recurrence within the surgical field occurred in left recurrent nerve, left tracheobronchial, left main bronchus and thoracic paraaortic lymph nodes, which were all difficult to approach to dissect. The other two local failures occurred around the anastomotic site. This study indicates that using RATE enabled the incidence of recurrence within the surgical field to be reduced, though there were some limitations.