Hybrid robotic versus hybrid laparoscopic Ivor Lewis oesophagectomy: a case-matched analysis

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Distortions in the Balance Between Teaching and Efficiency in the Operating Room

INTRODUCTION

The balance between teaching and operative efficiency (i.e., continuing operative case progression) is difficult for even the most experienced master surgeon educators. The purpose of this study was to explore influencing factors behind attending surgeons' decisions to break the balance between operative efficiency and teaching in the operating room.

METHODS

Semistructured interviews were conducted with surgeons across the United States via Web-based video conferencing. The interviews were audio-recorded and transcribed. Qualitative analysis using the framework method was utilized, and emergent themes were identified.

RESULTS

Twenty-three attending surgeons from 8 academic institutions and 11 surgical specialties completed interviews (14 men and 9 women). Attending surgeons consider a variety of factors associated with their dual roles (surgeon versus teacher) when balancing operative efficiency and providing appropriate independence for residents with oversight to promote autonomy. These were divided into surgeon-role-related factors (patient safety, financial factors, scheduling factors, preservation of faculty reputation for efficiency, and mode of operation) as well as teacher-role-related factors (preparation, level, and technical skill of the resident). These factors then informed attending surgeons' determinations about how the case was progressing, which prompted them to intervene and reduce resident autonomy or allow the resident to continue.

CONCLUSIONS

Surgeons consider numerous factors when deciding how to balance resident teaching and autonomy while preserving operative efficiency. These findings provide helpful insights for surgical departments to consider inclusion in faculty-development programs, resident education, and systematic improvements.

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.