Robotic-assisted minimally invasive esophagectomy for treatment of esophageal carcinoma

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Current status of robot-assisted minimally invasive esophagectomy: what is the real benefit?

Robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer has been performed increasingly frequently over the last few years. Robotic systems with articulated devices and tremor filtration allow surgeons to perform such procedures more meticulously than by hand. The feasibility of RAMIE has been demonstrated in several retrospective comparative studies, which showed similar short-term outcomes to conventional minimally invasive esophagectomy (cMIE). Considering the number of harvested lymph nodes, RAMIE may be superior to cMIE in terms of left upper mediastinal lymph node dissection. However, whether or not the addition of a robotic system to cMIE can help improve perioperative and oncological outcomes remains unclear. Given the lack of established evidence from randomized controlled trials, we must await the results of ongoing studies to reach any meaningful conclusions. Further advancements in robotic platforms, as well as the reduction in medical expenses, will be essential to demonstrate the real benefit of RAMIE.

[Initial experience of robot-assisted minimally invasive McKeown esophagectomy]

OBJECTIVE

To report our initial experience of robot-assisted McKeown esophagectomy with stapled cervical esophagogastrostomy.

MATERIAL AND METHODS

There were 5 robot-assisted McKeown esophagectomies in patients with benign end-staged and malignant diseases of the esophagus for the period from October 2019 to February 2020.

RESULTS

No conversions and intraoperative complications were observed. Mean surgery time was 406±48 min, total intraoperative blood loss - 108±45 ml. Four patients had minor complications (wound infection, atelectasis, pneumothorax) that required conservative treatment. We have controlled anastomosis in 2-3 postoperative days with water-soluble contrast, none patient had an anastomotic leakage. Mean hospital-stay was 5 days. Complete (R0) resection was accomplished in all patients with malignant neoplasms.

CONCLUSIONS

Our first experience showed that robot-assisted McKeown esophagectomy is a safe and feasible surgical option for esophageal diseases. Robot-assisted interventions require advanced endoscopic surgical experience.

Robot-assisted cervical esophagectomy: first clinical experiences and review of the literature

Pulmonary complications, and especially pneumonia, remain one of the most common complications after esophagectomy for esophageal cancer. These complications are reduced by minimally invasive techniques or by avoiding thoracic access through a transhiatal approach. However, a transhiatal approach does not allow for a full mediastinal lymphadenectomy. A transcervical mediastinal esophagectomy avoids thoracic access, which may contribute to a decrease in pulmonary complications after esophagectomy. In addition, this technique allows for a full mediastinal lymphadenectomy. A number of pioneering studies have been published on this topic. Here, the initial experience is presented as well as a review of the current literature concerning transcervical esophagectomy, with a focus on the robot-assisted cervical esophagectomy procedure.

Robot-assisted minimally invasive esophagectomy for esophageal cancer: Meticulous surgery minimizing postoperative complications

Minimally invasive esophagectomy (MIE) has been reported to reduce postoperative complications especially pulmonary complications and have equivalent long-term survival outcomes as compared to open esophagectomy. Robot-assisted minimally invasive esophagectomy (RAMIE) using da Vinci surgical system (Intuitive Surgical, Sunnyvale, USA) is rapidly gaining attention because it helps surgeons to perform meticulous surgical procedures. McKeown RAMIE has been preferably performed in East Asia where squamous cell carcinoma which lies in more proximal esophagus than adenocarcinoma is a predominant histological type of esophageal cancer. On the other hand, Ivor Lewis RAMIE has been preferably performed in the Western countries where adenocarcinoma including Barrett esophageal cancer is the most frequent histology. Average rates of postoperative complications have been reported to be lower in Ivor Lewis RAMIE than those in McKeown RAMIE. Ivor Lewis RAMIE may get more attention for thoracic esophageal cancer. The studies comparing RAMIE and MIE where recurrent nerve lymphadenectomy was thoroughly performed reported that the rate of recurrent nerve injury is lower in RAMIE than in MIE. Recurrent nerve injury leads to serious complications such as aspiration pneumonia. It seems highly probable that RAMIE is beneficial in performing recurrent nerve lymphadenectomy. Surgery for esophageal cancer will probably be more centralized in hospitals with surgical robots, which enable accurate lymph node dissection with less complications, leading to improved outcomes for patients with esophageal cancer. RAMIE might occupy an important position in surgery for esophageal cancer.

Recent advances in minimally invasive esophagectomy for squamous esophageal cancer

Over the past decade there has been tremendous development in the clinical application of minimally invasive esophagectomy (MIE) for the treatment of squamous esophageal carcinoma. The major challenges in the performance of MIE include limitations in visualization and manipulation within the confined, rigid thoracic cavity; the need for adequate patient positioning and anesthetic techniques to accommodate the surgical exposure; and changes in the surgical steps for achieving radical nodal dissection, especially for the superior mediastinum. The surgical procedure for MIE is more and more standardized, and there is an increasing practice of MIE worldwide. Randomized trials and meta-analyses have confirmed the advantages of MIE over open esophagectomy, including a significantly lower rate of complications and shorter hospital stays. The recent application of robotics technologies for MIE has further enhanced the quality and safety of the surgical dissection, while intraoperative nerve monitoring has contributed to a lower rate of recurrent laryngeal nerve palsy. With the application of new technologies, we expect further improvement in surgical outcomes for MIE in the treatment of squamous esophageal cancer.

Comparative outcomes of robot-assisted minimally invasive versus open esophagectomy in patients with esophageal squamous cell carcinoma: a propensity score-weighted analysis

Robots are increasingly used in minimally invasive surgery. We evaluated the clinical benefits of robot-assisted minimally invasive esophagectomy (RAMIE) in comparison with the conventional open esophageal surgery. From 2012 to 2016, 371 patients with esophageal squamous cell carcinoma underwent an Ivor Lewis or McKeown procedure at our institution. Of these, 130 patients underwent laparoscopic gastric conduit formation followed by RAMIE, whereas 241 patients underwent conventional esophageal surgery, including laparotomy and open esophagectomy (OE). We compared the short- and long-term clinical outcomes of these patients using the propensity score-based inverse probability of treatment weighting technique (IPTW). Among the early outcomes, the OE group showed a higher incidence of pneumonia (P = 0.035) and a higher requirement for vasopressors (P = 0.001). Regarding the long-term outcomes, all-cause mortality was significantly higher (P = 0.001) and disease-free survival was lower (P = 0.006) in the OE group. Wound-related problems also occurred more frequently in the OE group (P = 0.020) during the long-term follow-up. There was no statistical intergroup difference in the recurrence rates (P = 0.191). The Cox proportional-hazard analysis demonstrated that wound problems (HR 0.16, 95% CI 0.02-0.57; P = 0.017), pneumonia (HR 0.23, 95% CI 0.06-0.68; P = 0.019), and use of vasopressors (HR 0.14, 95% CI 0.08-0.25; P = 0.001) were independent predictors of mortality. RAMIE could be a better surgical option for selected patients with esophageal squamous cell carcinoma.

Compare the prognosis of Da Vinci robot-assisted thoracic surgery (RATS) with video-assisted thoracic surgery (VATS) for non-small cell lung cancer: A Meta-analysis

To determine if there are advantages to transitioning to Da Vinci robotics by a surgeon compared to the video-assisted thoracic surgical lobectomy.A systematic electronic search of online electronic databases: PubMed, Embase, and Cochrane library updated on December 2017. Publications on comparison Da Vinci-robot-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS) for non-small cell lung cancer were collected. Meta-analysis RevMan 5.3 software (The Cochrane collaboration, Oxford, UK) was used to analyze the combined pooled HRs using fixed or random-effects models according to the heterogeneity.Fourteen retrospective cohort studies were included. No statistical difference was found between the 2 groups with respect to conversion to open, dissected lymph nodes number, hospitalization time after surgery, duration of surgery, drainage volume after surgery, prolonged air leak, and morbidity (P > .05).Da Vinci-RATS lobectomy is a feasible and safe technique and can achieve an equivalent surgical efficacy when compared with VATS. There does not seem to be a significant advantage for an established VATS lobectomy surgeon to transition to robotics based on clinical outcomes.

Transcervical minimally invasive esophagectomy using da Vinci® SP™ Surgical System: a feasibility study in cadaveric model

BACKGROUND

This is a preclinical cadaveric study to investigate the feasibility of transcervical esophagectomy using a novel single-port robotic surgical system.

METHODS

A 40-mm cervical incision was created over left supraclavicular fossa. The novel da Vinci® SP™ Surgical System was introduced through a wound retraction port. The mobilization of esophagus was performed using da Vinci SP from cervical, thoracic to abdominal segments. Lymph nodes were dissected en bloc with esophagus.

RESULTS

The transcervical esophagectomy with complete mobilization of the cervical, thoracic, and abdominal esophagus was completed in 60 min. The procedure was completed using the novel da Vinci SP Surgical System, which was introduced via the cranial side over the left cervical incision. No additional port was used for retraction and dissection, and the esophageal hiatus could be reached after complete transcervical dissection.

CONCLUSION

This preclinical study demonstrated that transcervical esophagectomy is technically feasible and can be completed with the novel da Vinci SP Surgical System without additional ports or assistance. This will serve as an important step to the performance of robotic transcervical esophagectomy without the necessity of one-lung ventilation.

Robot assisted esophagectomy for esophageal squamous cell carcinoma

Background

This study aims to report our experience with robot assisted esophagectomy (RAE) for the treatment of resectable esophageal squamous cell carcinoma (ESCC).

Methods

A series of 249 consecutive patients diagnosed with ESCC who underwent RAE from November 2015 to December 2017 at Shanghai Chest Hospital were evaluated, and their clinical data were reviewed retrospectively. One hundred patients were equally divided into four groups according to the surgery order, and the short-term outcomes in each group were analyzed.

Results

Overall, 249 patients (201 males and 48 females) with a mean age of 63.4±7.3 years who underwent RAE were analyzed. The thoracic procedure was successfully performed with the assistance of a robot. The mean total duration was 250.6±58.4 mins, and the estimated blood loss was 215.5±87.6 mL. R0 resection was performed in 232 (93.2%) patients with a mean total number of dissected lymph nodes of 18.5±9.1 and mean yield of lymph nodes along the recurrent laryngeal nerve (RLN) of 4.4±3.2. The median postoperative hospital stay was 11 days, and no 90-day mortality was observed. Forty-five (18.1%) patients experienced pulmonary complications, and the recurrent laryngeal nerve injury were observed in 38 (15.3%) patients. A significant reduction in thoracic duration was observed after the initial 25 cases (P<0.001). After 50 cases, the dissection of total lymph nodes, mediastinum lymph nodes and lymph nodes along the RLN were significantly improved (P<0.001, P<0.001, P=0.001, respectively) with a shorter postoperative hospital stay (P=0.005).

Conclusions

RAE is a safe and feasible alternative surgical approach for resectable esophageal carcinoma and is associated with a large yield of lymph nodes, especially along the RLN. The surgeon will reach a plateau of operative duration after 25 cases and a plateau of lymphadenectomy after 50 cases.

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

Three-dimensional video-assisted thoracic surgery for pulmonary resections: an update

Video-assisted thoracic surgery (VATS) allows to treat pulmonary and mediastinal diseases although two-dimensional (2D) imaging can make difficult to estimate the morphological and topographical characteristics of a lesion. Some technical aspects have certainly been corrected with the introduction of robot-assisted thoracic surgery (RATS), although not widespread in less economically developed countries. As an emerging imaging system and technique, 3D VATS is an interesting resource for thoracic surgeons and it may be a proper and valid aid in minimally-invasive surgery, but not an alternative or a compromise to the most expensive robotic technology. The purpose of the study was to carefully analyze the different experiences reported in literature in order to evaluate the state of art of 3D VATS method in lung excision.

Robotic surgery for esophageal cancer: Merits and demerits

Since the introduction of robotic systems in esophageal surgery in 2000, the number of robotic esophagectomies has been gradually increasing worldwide, although robot‐assisted surgery is not yet regarded as standard treatment for esophageal cancer, because of its high cost and the paucity of high‐level evidence. In 2016, more than 1800 cases were operated with robot assistance. Early results with small series demonstrated feasibility and safety in both robotic transhiatal (THE) and transthoracic esophagectomies (TTE). Some studies report that the learning curve is approximately 20 cases. Following the initial series, operative results of robotic TTE have shown a tendency to improve, and oncological long‐term results are reported to be effective and acceptable: R0 resection approaches 95%, and locoregional recurrence is rare. Several recent studies have demonstrated advantages of robotic esophagectomy in lymphadenectomy compared with the thoracoscopic approach. Such technical innovations as three‐dimensional view, articulated instruments with seven degrees of movement, tremor filter etc. have the potential to outperform any conventional procedures. With the aim of preventing postoperative pulmonary complications without diminishing lymphadenectomy performance, a nontransthoracic radical esophagectomy procedure combining a video‐assisted cervical approach for the upper mediastinum and a robot‐assisted transhiatal approach for the middle and lower mediastinum, transmediastinal esophagectomy, was developed; its short‐term outcomes are promising.

Thus, the merits or demerits of robotic surgery in this field remain quite difficult to assess. However, in the near future, the merits will definitely outweigh the demerits because the esophagus is an ideal organ for a robotic approach.