Robot-assisted thoracolaparoscopic esophagolymphadenectomy for esophageal cancer

[Minimally invasive and robotic-assisted surgical management of upper gastrointestinal cancer]

Total minimally invasive upper gastrointestinal resections are currently mainly performed in centers. The advantages include reduction of operative trauma, magnified enlargement of the operation field and the resulting improvement in operative precision. Robotic-assisted minimally invasive esophagectomy (RAMIE) and laparoscopic/thoracoscopic minimally invasive esophagectomy (MIE) are currently the most commonly performed strategies for esophageal cancer. Laparoscopic (MIG) and robotic-assisted gastrectomy (RAG) are the equivalent procedures for gastric cancer. Due to the relatively low number of reported cases, no definitive statement regarding superiority of these procedures compared to standard open or hybrid procedures can be made; however, there is mounting evidence from high-volume centers in which these procedures are routinely performed that there might be an advantage regarding perioperative morbidity. All of the four procedures described are provided at our high-volume centers in a standardized manner and we are convinced of the benefits of these minimally invasive techniques with respect to morbidity compared to open and hybrid techniques. The additional costs of this technology have to be off-set against a possible reduction of morbidity, reduced cost for personnel and new operative options, such as real-time fluoroscopy.

Robotic-assisted minimally invasive esophagectomy versus the conventional minimally invasive one: A meta-analysis and systematic review

BACKGROUND

Conventional video-assisted minimally invasive esophagectomy (MIE) is safe and associated with low rates of morbidity and mortality, but the two-dimensional monitor reduces eye-hand harmony and viewing yield. Robotic-assisted minimally invasive esophagectomy (RAMIE) with its virtual reality simulators offers a realistic three-dimensional environment that facilitates dissection in the narrow working space, but it is expensive and requires longer operative time. Therefore, the aim of this meta-analysis was to assess the safety and feasibility of RAMIE versus MIE in patients with esophageal cancer.

MATERIAL AND METHODS

PubMed, EMBASE, Cochrane library, and Chinese Biomedical Literature databases were systematically searched up to 21 September 2018 for case-controlled studies that compared RAMIE with MIE.

RESULT

Eight case-controlled studies involving 1862 patients (931 under RAMIE and 931 under MIE) were considered. No statistically significant difference between the two techniques was observed regarding R0 resection rate (OR = 1.1174, P = 0.8647), conversion to open (OR = 0.7095, P = 0.7519), 30-day mortality rate (OR = 0.8341, P = 0.7696), 90-day mortality rate (OR = 0.3224, P = 0.3329), in-hospital mortality rate (OR = 0.3733, P = 0.3895), postoperative complications, number of harvested lymph nodes (mean difference [MD] = 0.8216, P = 0.2039), operation time (MD = 24.3655 min, P = 0.2402), and length of stay in hospitals (LOS) (MD = -5.0228 day, P = 0.1342). The meta-analysis showed that RAMIE was associated with a significantly fewer estimated blood loss (EBL) (MD = -33.2268 mL, P = 0.0075). And the vocal cord palsy rate was higher in the MIE group compared with RAMIE, and the difference was significant (OR = 0.5696, P = 0.0447).

CONCLUSION

This meta-analysis indicated that RAMIE and MIE display similar feasibility and safety when used in esophagectomy. However, randomized controlled studies with larger sample sizes are needed to evaluate the benefit and harm in patients with esophageal cancer undergoing RAMIE.

Robotic oesophago-gastric cancer surgery

A postoperative complications rate of nearly 50% has compelled oesophago-gastric practice to adopt minimally invasive techniques such as robotic surgery

Modified exposure method for gastric mobilization in robot-assisted esophagectomy

Background

We describe a modified method to facilitate gastric mobilization in robotic esophagectomy. Furthermore, we performed a prospective comparative analysis of surgical outcomes between the conventional method and described technique.

Methods

From April 1st, 2016 to December 31st, 2016, 59 consecutive patients were included who underwent robot-assisted McKeown esophagectomy for esophageal squamous cell carcinoma in our institution. They were subdivided into two groups based on the method of gastric exposure: a grasper retraction (GR) group (n=27) and a thread retraction (TR) group (n=32). For the GR patients, robotic instruments were directly used to expose the surgical field for gastric mobilization. However, for TR patients, the right gastroepiploic arcade and the short gastric vessels were fully exposed via a polyester tape combined with a thread loop.

Results

There was no incidence of postoperative 30-day mortality. The median gastric mobilization time was 53 min (range, 38-77 min). It took significantly less time in the TR group compared to the GR group (P=0.005). The median amount of blood loss was 8 mL (range, 5-14 mL), and no significant difference was found between the two groups (P=0.573). The median number of dissected lymph nodes was 10 (range, 7-16), and there was no significant difference between groups (P=0.386). Similarly, the postoperative morbidity rates did not statistically differ between the two groups (P=0.942).

Conclusions

The robot-assisted McKeown procedure presented is a safe and easy to perform technique for stomach retraction during gastric mobilization. Compared with the conventional GR method of gastric mobilization, TR requires less operating time and allows for an excellent operative field. The technique could, therefore, help surgeons to overcome some of the defects of robotic esophagectomy during gastric mobilization.

Pan-Cancer Analysis Links PARK2 to BCL-XL-Dependent Control of Apoptosis

Mutation of the PARK2 gene can promote both Parkinson's Disease and cancer, yet the underlying mechanisms of how PARK2 controls cellular physiology is incompletely understood. Here, we show that the PARK2 tumor suppressor controls the apoptotic regulator BCL-XL and modulates programmed cell death. Analysis of approximately 10,000 tumor genomes uncovers a striking pattern of mutual exclusivity between PARK2 genetic loss and amplification of BCL2L1, implicating these genes in a common pathway. PARK2 directly binds to and ubiquitinates BCL-XL. Inactivation of PARK2 leads to aberrant accumulation of BCL-XL both in vitro and in vivo, and cancer-specific mutations in PARK2 abrogate the ability of the ubiquitin E3 ligase to target BCL-XL for degradation. Furthermore, PARK2 modulates mitochondrial depolarization and apoptosis in a BCL-XL-dependent manner. Thus, like genes at the nodal points of growth arrest pathways such as p53, the PARK2 tumor suppressor is able to exert its antiproliferative effects by regulating both cell cycle progression and programmed cell death.

Total minimally invasive esophagectomy for esophageal cancer: approaches and outcomes

Since the introduction of minimally invasive esophagectomy 25 years ago, its use has been reported in several high volume centers. With only one published randomized control trial and five meta-analyses comparing its outcomes to open esophagectomy, available level I evidence is very limited. Available technical approaches include total minimally invasive transthoracic (Ivor Lewis or McKeown) or transhiatal esophagectomy; several hybrid options are available with one portion of the procedure completed via an open approach. A review of available level I evidence with focus on total minimally invasive esophagectomy is presented. The old debate regarding the superiority of a transthoracic versus transhiatal approach to esophagectomy may have been settled by minimally invasive esophagectomy as only few centers are reporting on the latter being utilized. The studies with the highest level of evidence available currently show that minimally invasive techniques via a transthoracic approach are associated with less overall morbidity, fewer pulmonary complications, and shorter hospital stays than open esophagectomy. There appears to be no detrimental effect on oncologic outcomes and possibly an added benefit derived by improved lymph node retrieval. Quality of life improvements may also translate into improved survival, but no conclusive evidence exists to support this claim. Robotic and hybrid techniques have also been implemented, but there currently is no evidence showing that these are superior to other minimally invasive techniques.