Impact of surgical approach on perioperative and long-term outcomes following esophagectomy for esophageal cancer

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.

Short- and Long-Term Outcomes of Totally Versus Hybrid Minimally Invasive Ivor Lewis Oesophagectomy for Oesophageal Cancer: A Propensity Score-Matched Analysis

Background

Few objective studies have compared totally minimally invasive Ivor Lewis oesophagectomy with hybrid procedure. Here we investigated whether the choice between totally and hybrid minimally invasive Ivor Lewis oesophagectomy influenced short-term outcomes and long-term patient survival.

Methods

Patients who underwent totally or hybrid minimally invasive Ivor Lewis oesophagectomy between January 2014 and December 2017 were propensity score matched in a 1:1 ratio. The short- and long-term outcomes between the two groups were compared before and after matching.

Results

Of 138 totally and 156 hybrid minimally invasive oesophagectomy patients were eligible, 104 patients from each group were propensity score matched. Totally minimally invasive oesophagectomy was associated significantly with less blood loss (median(IQR) 100(60-150) vs 120(120-200) ml respectively; P < 0.001), pneumonia (13.5 vs 25.0%; P = 0.035), pleural effusion (3.8 vs 13.5%; P = 0.014), and chest drainage (7.5(6-9) vs 8(7-9) days; P = 0.009) than hybrid procedure. There was no significant difference in 3-year overall survival rate and 3-year disease-free survival rate between the two group.

Conclusions

Totally minimally invasive Ivor Lewis oesophagectomy may improve short-term outcomes and specifically reduce the incidence of pulmonary complications compared with hybrid procedure. The long-term overall survival and disease-free survival rates between the two groups were similar.

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.

Early implementation of a perioperative nutrition support pathway for patients undergoing esophagectomy for esophageal cancer

Background

Unintentional weight loss and malnutrition are associated with poorer prognosis in patients with cancer. Risk of cancer‐associated malnutrition is highest among patients with esophageal cancer (EC) and has been repeatedly shown to be an independent risk factor for worse survival in these patients. Implementation of nutrition protocols may reduce postoperative weight loss and enhance recovery in these patients.

Methods

We retrospectively identified all patients who underwent Ivor Lewis esophagectomy for EC from January 2015 to August 2019 from a prospectively collected institutional database. Patients who underwent surgery after the implementation of this protocol (September 2017–August 2019) were compared with patients who underwent resection before protocol implementation (January 2015–July 2017). Patients undergoing surgery during the month of protocol initiation were excluded.

Results

Of the 404 patients included in our study, 217 were in the preprotocol group, and 187 were in the postprotocol group. Compared with the preprotocol group, there were significant reductions in length of hospital stay (p < 0.001), time to diet initiation (p < 0.001), time to feeding tube removal (p = 0.012), and postoperative weight loss (p = 0.002) in the postprotocol group. There was no significant difference in the incidence of postoperative complications, 30‐day readmission, or mortality rates between groups.

Conclusions

Results of the present study suggest a standardized perioperative nutrition protocol may prevent unintentional weight loss and improve postoperative outcomes in patients with EC undergoing resection.

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.

The Impact of Hybrid Minimally Invasive Esophagectomy with Neck-Abdominal First Approach on the Short- and Long-Term Outcomes for Esophageal Squamous Cell Carcinoma

BACKGROUND

Currently, there is no consensus for an optimal minimally invasive esophagectomy (MIE) approach. This study aimed to compare hybrid MIE (hMIE) with neck-abdominal first approach to standard open esophagectomy (OE).

METHODS

Data from a cohort of 301 patients were retrospectively analyzed. All participants received either hMIE or OE for the treatment of esophageal squamous cell carcinoma at Tokyo Medical and Dental University between January 2003 and December 2013. Analyses included propensity score matching and the Kaplan-Meier statistical method to determine overall survival (OS) and disease-free survival (DFS) of the cohort.

RESULTS

After one-to-one propensity score matching, there were 68 patient pairs. The hMIE group had significantly lower incidence of severe postoperative complications (20.1% vs. 7.4%; p = 0.026) and severe respiratory complications (7.4% vs. 0%; p = 0.058) than the OE group. The 5-year oncological outcomes of the two groups were almost equivalent (OS: OE, 55.0%; hMIE, 69.0%; p = 0.063 and DFS: OE, 54.0%; hMIE, 62.0%; p = 0.28).

CONCLUSIONS

This study compared hMIE with neck-abdominal first approach to standard OE. The results showed significantly less severe postoperative complications for hMIE with neck-abdominal first approach in comparison with OE, without a compromise in long-term oncological outcomes.

Using Benchmarking Standards to Evaluate Transition to Minimally Invasive Esophagectomy

BACKGROUND

Minimally invasive esophagectomy (MIE) is performed in nearly 50% of patients worldwide. The effectiveness of the technique arises from a single randomized control trial and multiple single series cohorts. Consistent reporting of complications is varied. We describe our experience of transitioning to MIE compared with open esophagectomy (OE) with the use of Esophageal Complications Consensus Group (ECCG) standardized complication benchmark definitions.

METHODS

Between 2007 and 2017, all patients undergoing esophagectomy were identified with the use of a prospectively curated database. Complications were defined by the ECCG and graded with the Clavien-Dindo (most severe complication) and comprehensive complication index (complexity of complications during hospital stay).

RESULTS

Of 383 patients, 299 (76%) were men with a median age of 64.5 years (range, 56-72 years). MIE was performed in 49.6%. No differences were found in age, histologic finding (P = .222), pT stage (P = .136), or nodal positivity (P = .918). Stage 3 cancers accounted for 42.0% of OEs and 47.9% of MIEs. A thoracic anastomosis was more frequent in MIEs (156 of 190; 82.1%) than in OEs (113 of 193; 58.5%; P = .001). Frequency, severity (Clavien-Dindo), and complexity (comprehensive complication index) of complications were better in the MIE group, without compromising operative outcomes. No differences were identified in individual complication groupings or grade in MIEs compared with OEs (pneumonia: 19.5% versus 26.9% ([P = .09]; intensive care unit readmission: 7.4% versus 9.3% [P = .519]; atrial fibrillation: 11.1% versus 6.7% [P = .082], or grade of leak [P = .99]).

CONCLUSIONS

These results compare favorably to those reported by ECCG. MIE can be the standard approach for surgical management of esophageal cancer. Introduction of the approach in each surgeon's practice should be benchmarked to international standards.

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.

Meaning of C-reactive protein around esophagectomy for cStage III esophageal cancer

PURPOSE

The prognosis of esophageal cancer is dismal, and the 3-year overall survival of cStage III does not reach 50.0%. C-reactive protein (CRP) is a well-known protein that reflects the short- and long-term operative outcomes of esophageal cancer. However, since elevated CRP levels are often observed in cStage III esophageal cancer, whether or not CRP still reflects the prognosis is unclear.

METHODS

Eighty-four patients who were diagnosed with cStage III esophageal cancer and underwent R0/1 operation from January 2007 to December 2014 were retrospectively evaluated.

RESULTS

The mean age was 66.8 years, and the majority of patients were male. The median preoperative and postoperative CRP levels were 0.15 and 1.47 mg/dl, respectively. A majority of the patients underwent thoracoscopic surgery, and the median blood loss and operation duration were 456 ml and 11.6 h, respectively. Forty-six patients (54.8%) died during the observation period, and the 3-year overall survival was 52.4%. A multivariate analysis showed that the preoperative CRP level, postoperative albumin level, blood loss, and complications were independent prognostic factors. A multiple linear regression analysis showed that an elevated postoperative CRP level was affected by the operation duration and preoperative CRP levels.

CONCLUSIONS

These findings suggest that the preoperative CRP level is a prognostic factor for cStage III esophageal cancer and that postoperative elevation in the CRP level is affected by the operation duration.