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Patel NM, Patel PH, Yeung KTD, Monk D, Mohammadi B, Mughal M, Bhogal RH, Allum W, Abbassi-Ghadi N, Kumar S. Is Robotic Surgery the Future for Resectable Esophageal Cancer?: A Systematic Literature Review of Oncological and Clinical Outcomes. Ann Surg Oncol 2024; 31:4281-4297. [PMID: 38480565 PMCID: PMC11164768 DOI: 10.1245/s10434-024-15148-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/19/2024] [Indexed: 06/13/2024]
Abstract
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.
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Affiliation(s)
- Nikhil Manish Patel
- Department of Upper GI Surgery, The Royal Marsden NHS Foundation Trust, London, UK
- The Upper Gastrointestinal Surgical Oncology Research Group, The Institute of Cancer Research, London, UK
| | - Pranav Harshad Patel
- Department of Upper GI Surgery, The Royal Marsden NHS Foundation Trust, London, UK
- The Upper Gastrointestinal Surgical Oncology Research Group, The Institute of Cancer Research, London, UK
| | - Kai Tai Derek Yeung
- Department of Upper GI Surgery, The Royal Marsden NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - David Monk
- Department of Upper Gastrointestinal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic London Hospital, London, UK
| | - Borzoueh Mohammadi
- Department of Upper Gastrointestinal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic London Hospital, London, UK
| | - Muntzer Mughal
- Department of Upper Gastrointestinal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic London Hospital, London, UK
| | - Ricky Harminder Bhogal
- Department of Upper GI Surgery, The Royal Marsden NHS Foundation Trust, London, UK
- The Upper Gastrointestinal Surgical Oncology Research Group, The Institute of Cancer Research, London, UK
| | - William Allum
- Department of Upper GI Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Nima Abbassi-Ghadi
- Department of Upper GI Surgery, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
| | - Sacheen Kumar
- Department of Upper GI Surgery, The Royal Marsden NHS Foundation Trust, London, UK.
- The Upper Gastrointestinal Surgical Oncology Research Group, The Institute of Cancer Research, London, UK.
- Department of Upper Gastrointestinal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic London Hospital, London, UK.
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Bondzi-Simpson A, Ribeiro T, Grant A, Ko M, Coburn N, Hallet J, Kulkarni GS, Kidane B. Patients with complete clinical response after neoadjuvant chemoradiotherapy for locally advanced esophageal cancer: A Markov decision analysis of esophagectomy versus active surveillance. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00364-7. [PMID: 38649112 DOI: 10.1016/j.jtcvs.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 03/07/2024] [Accepted: 04/12/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Chemoradiation followed by esophagectomy is a standard treatment option for patients with locally advanced esophageal cancer (LAEC). Esophagectomy is a high-risk procedure, and recent evidence suggests select patients may benefit from omitting or delaying surgery. This study aims to compare surgery versus active surveillance for LAEC patients with complete clinical response (cCR) after neoadjuvant chemoradiotherapy (nCRT). METHODS Decision analysis with Markov modeling was used. The base case was a 60-year-old man with T3N0M0 esophageal cancer with cCR after nCRT. The decision was modeled for a 5-year time horizon. Primary outcomes were life-years and quality-adjusted life-years (QALY). Probabilities and utilities were derived through the literature. Deterministic sensitivity analyses were performed using ranges from the literature with consideration for clinical plausibility. RESULTS Surgery was favored for survival with an expected life-years of 2.89 versus 2.64. After incorporating quality of life, active surveillance was favored, with an expected QALY of 1.70 versus 1.56. The model was sensitive to probability of recurrence on active surveillance (threshold value 0.598), probability of recurrence being resectable (0.318), and disutility of previous esophagectomy (-0.091). The model was not sensitive to perioperative morbidity and mortality. CONCLUSIONS Our study finds that surgery increases life expectancy but decreases QALY. Although the incremental change in QALY for either modality is insufficient to make broad clinical recommendations, our study demonstrates that either approach is acceptable. As probabilities of key factors are further defined in the literature, treatment decisions for patients with LAEC and a cCR after nCRT should consider histology, patient values, and quality of life.
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Affiliation(s)
- Adom Bondzi-Simpson
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tiago Ribeiro
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Angelo Grant
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael Ko
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, St Joseph's Health Centre, University of Toronto, Toronto, Canada
| | - Natalie Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Surgical Oncology, Odette Cancer Centre-Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Surgical Oncology, Odette Cancer Centre-Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Girish S Kulkarni
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada
| | - Biniam Kidane
- Section of Thoracic Surgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Cancer Care Manitoba Research Institute, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Physiology & Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Biomedical Engineering, University of Manitoba, Winnipeg, Manitoba, Canada.
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Puntambekar S, Bharambe S, Pawar S, Chitale M, Panse M. Feasibility of transthoracic esophagectomy with a next-generation surgical robot. Sci Rep 2022; 12:17925. [PMID: 36289257 PMCID: PMC9606257 DOI: 10.1038/s41598-022-21323-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 09/26/2022] [Indexed: 01/20/2023] Open
Abstract
Robot-assisted minimal access surgery (MAS), compared with conventional MAS, has shown a number of benefits across several therapeutic indications but its use for transthoracic esophagectomy (TTE) requires further evaluation. Here, we report the first-in-human series of major esophageal resections performed using a next-generation tele-operated robotic surgical system in a single center. Robot-assisted TTE was performed using the Versius Surgical System by a single surgeon to assess the robotic system's ability to achieve tumor clearance (measured by R0 resection rates) whilst reducing anastomotic leakage rates. Intra- and post-operative outcomes such as median operative time, length of hospitalization, intra-operative blood loss, and the number of complications were also assessed. Fifty-seven patients underwent robot-assisted TTE between August 2019 and June 2021. All procedures were completed successfully with no unplanned conversions to alternative surgical methods. Estimated blood loss was minimal, and no adverse events, complications or deaths were reported. Our experience with the Versius Surgical System demonstrates its safe adoption and implementation for TTE.
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Affiliation(s)
- Shailesh Puntambekar
- Galaxy Care Laparoscopy Institute, Galaxy Care Hospital, Pune, Maharashtra India
| | - Suyog Bharambe
- Galaxy Care Laparoscopy Institute, Galaxy Care Hospital, Pune, Maharashtra India
| | - Swapnil Pawar
- Galaxy Care Laparoscopy Institute, Galaxy Care Hospital, Pune, Maharashtra India
| | - Mihir Chitale
- Galaxy Care Laparoscopy Institute, Galaxy Care Hospital, Pune, Maharashtra India
| | - Mangesh Panse
- Galaxy Care Laparoscopy Institute, Galaxy Care Hospital, Pune, Maharashtra India
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Kanamori J, Watanabe M, Maruyama S, Kanie Y, Fujiwara D, Sakamoto K, Okamura A, Imamura Y. Current status of robot-assisted minimally invasive esophagectomy: what is the real benefit? Surg Today 2021; 52:1246-1253. [PMID: 34853881 DOI: 10.1007/s00595-021-02432-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/26/2021] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Jun Kanamori
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Masayuki Watanabe
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Suguru Maruyama
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yasukazu Kanie
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Daisuke Fujiwara
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Kei Sakamoto
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akihiko Okamura
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Imamura
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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