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Hoelzen JP, Fortmann L, Roy D, Szardenings C, Holstein M, Eichelmann AK, Rijcken E, Frankauer BE, Barth P, Wardelmann E, Pascher A, Juratli MA. Robotic-assisted esophagectomy with total mesoesophageal excision enhances R0-resection in patients with esophageal cancer: A single-center experience. Surgery 2024; 176:721-729. [PMID: 38944589 DOI: 10.1016/j.surg.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 03/19/2024] [Accepted: 05/13/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND The focus of this research is to examine the growing use of robotic-assisted minimally invasive esophagectomy. Specifically, it evaluates the immediate clinical and cancer-related results of combining robotic-assisted minimally invasive esophagectomy with a systematic approach to total mesoesophageal excision, as opposed to traditional open transthoracic esophagectomy methods that do not employ a structured total mesoesophageal excision protocol. METHODS A propensity score-matched analysis of 185 robotic-assisted minimally invasive esophagectomies and 223 open transthoracic esophagectomies after standardized Ivor Lewis esophagectomy was performed. After 1:1 nearest neighbor matching to account for confounding by covariates, outcomes of 181 robotic-assisted minimally invasive esophagectomy and 181 open transthoracic esophagectomy were compared. RESULTS The patient characteristics showed significant differences in the age distribution and in comorbidities such as coronary heart disease, arterial hypertension, and anticoagulant intake. The R0-resection rate of robotic-assisted minimally invasive esophagectomy (96.7%) was significantly higher than open transthoracic esophagectomy (89.0%, P = .004). Thirty-day mortality and hospital mortality showed no significant differences. Postoperative pneumonia rate after robotic-assisted minimally invasive esophagectomy (12.7%) was significantly reduced (open transthoracic esophagectomy 28.7%, P < .001). Robotic-assisted minimally invasive esophagectomy had a significantly shorter intensive care unit stay (P < .001) and shorter hospital stay (P < .001). CONCLUSION This single-center, retrospective study employing propensity score matching found that combining robotic-assisted minimally invasive esophagectomy with structured total mesoesophageal excision results in better short-term clinical and oncologic outcomes than open transthoracic esophagectomy. This finding is significant because the increased rate of R0 resection could indicate a higher likelihood of improved long-term survival. Additionally, enhanced overall postoperative recovery may contribute to better risk management in esophagectomy procedures.
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Affiliation(s)
- Jens P Hoelzen
- Department of General, Visceral, and Transplant Surgery, University Hospital Muenster, University of Muenster, Germany
| | - Lukas Fortmann
- Department of General, Visceral, and Transplant Surgery, University Hospital Muenster, University of Muenster, Germany
| | - Dhruvajyoti Roy
- Department of Breast Surgical Oncology, University Hospital of Texas, MD Anderson Cancer Center, Houston, TX
| | - Carsten Szardenings
- Institute of Biostatistics and Clinical Research, University of Muenster, Germany
| | - Martina Holstein
- Department of General, Visceral, and Transplant Surgery, University Hospital Muenster, University of Muenster, Germany
| | - Ann-Kathrin Eichelmann
- Department of General, Visceral, and Transplant Surgery, University Hospital Muenster, University of Muenster, Germany
| | - Emile Rijcken
- Department of General, Visceral, and Transplant Surgery, University Hospital Muenster, University of Muenster, Germany
| | - Brooke E Frankauer
- Department of General, Visceral, and Transplant Surgery, University Hospital Muenster, University of Muenster, Germany
| | - Peter Barth
- Gerhard-Domagk-Institute of Pathology, University Hospital Muenster, Germany
| | - Eva Wardelmann
- Gerhard-Domagk-Institute of Pathology, University Hospital Muenster, Germany
| | - Andreas Pascher
- Department of General, Visceral, and Transplant Surgery, University Hospital Muenster, University of Muenster, Germany
| | - Mazen A Juratli
- Department of General, Visceral, and Transplant Surgery, University Hospital Muenster, University of Muenster, Germany.
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Bjelovic M, Gunjic D, Babic T, Veselinovic M, Djukanovic M, Potkonjak D, Milosavljevic V. Safe Transition from Open to Total Minimally Invasive Esophagectomy for Cancer Utilizing Process Management Methodology. J Clin Med 2024; 13:4364. [PMID: 39124631 PMCID: PMC11312586 DOI: 10.3390/jcm13154364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/14/2024] [Accepted: 07/17/2024] [Indexed: 08/12/2024] Open
Abstract
Background: The global shift from open esophagectomy (OE) to minimally invasive esophagectomy (MIE) for treating esophageal cancer is well-established. Recent data indicate that transitioning from hybrid minimally invasive esophagectomy (hMIE) to total minimally invasive esophagectomy (tMIE) can be challenging due to concerns about higher leakage rates and lower lymph node counts, especially at the beginning of the learning curve. This study aimed to demonstrate that a safe transition from OE to tMIE for cancer is possible using process management methodology. Methods: A step-change approach was adopted in process management planning, with hMIE serving as an intermediate step between OE and tMIE. This single-center, case-control study included 150 patients who underwent the Ivor Lewis procedure with curative intent for esophageal cancer. Among these patients, 50 underwent OE, 50 hMIE (laparoscopic procedure followed by conventional right thoracotomy), and 50 tMIE (laparoscopic and thoracoscopic approach). A preceptored training scheme was implemented during execution, and treatment results were monitored and controlled to ensure a safe transition. Results: During the transition, the tMIE group was not worse than the hMIE and OE groups regarding operation duration (p = 0.135), overall postoperative complications (p = 0.020), anastomotic leakage rates (p = 0.773), 30-day mortality (p = 1.0), and oncological outcomes (based on R status (p = 0.628) and 2-year survival (p = 0.967)). Additionally, the tMIE group showed superior results in terms of major postoperative pulmonary complications (p = 0.004) and ICU stay duration (p < 0.001). Conclusions: Utilizing managerial methodology and practice in surgery, as a bridge between interdisciplinary and transdisciplinary approaches, demonstrated that transitioning from OE to tMIE, with hMIE as an intermediate step, is safe and feasible without compromising outcomes.
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Affiliation(s)
- Milos Bjelovic
- Euromedic General Hospital, Bulevar umetnosti 29, 11070 Belgrade, Serbia;
- School of Medicine Foca, University East Sarajevo, Studentska 5, 73300 Foca, Bosnia and Herzegovina
| | - Dragan Gunjic
- Euromedic General Hospital, Bulevar umetnosti 29, 11070 Belgrade, Serbia;
| | - Tamara Babic
- Department for Minimally Invasive Upper Digestive Surgery, Hospital for Digestive Surgery, Clinical Center of Serbia, Dr Koste Todorovica Street 6, 11000 Belgrade, Serbia; (T.B.); (M.V.); (D.P.)
| | - Milan Veselinovic
- Department for Minimally Invasive Upper Digestive Surgery, Hospital for Digestive Surgery, Clinical Center of Serbia, Dr Koste Todorovica Street 6, 11000 Belgrade, Serbia; (T.B.); (M.V.); (D.P.)
- School of Medicine, University of Belgrade, Dr Subotica Street 8, 11000 Belgrade, Serbia
| | - Marija Djukanovic
- Department of Anesthesiology and Resuscitation, Hospital for Digestive Surgery, Clinical Center of Serbia, Dr Koste Todorovica Street 6, 11000 Belgrade, Serbia;
| | - Dario Potkonjak
- Department for Minimally Invasive Upper Digestive Surgery, Hospital for Digestive Surgery, Clinical Center of Serbia, Dr Koste Todorovica Street 6, 11000 Belgrade, Serbia; (T.B.); (M.V.); (D.P.)
| | - Vladimir Milosavljevic
- University Hospital Medical Center Bezanijska Kosa, Dr Zorza Matea Street, 11000 Belgrade, Serbia;
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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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Perry R, Barbosa JP, Perry I, Barbosa J. Short-term outcomes of robot-assisted versus conventional minimally invasive esophagectomy for esophageal cancer: a systematic review and meta-analysis of 18,187 patients. J Robot Surg 2024; 18:125. [PMID: 38492067 PMCID: PMC10944433 DOI: 10.1007/s11701-024-01880-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/20/2024] [Indexed: 03/18/2024]
Abstract
The role of robotic surgery in the curative-intent treatment of esophageal cancer patients is yet to be defined. To compare short-term outcomes between conventional minimally invasive (cMIE) and robot-assisted minimally invasive esophagectomy (RAMIE) in esophageal cancer patients. PubMed, Web of Science and Cochrane Library were systematically searched. The included studies compared short-term outcomes between cMIE and RAMIE. Individual risk of bias was calculated using the MINORS and RoB2 scales. There were no statistically significant differences between RAMIE and cMIE regarding conversion to open procedure, mean number of harvested lymph nodes in the mediastinum, abdomen and along the right recurrent laryngeal nerve (RLN), 30- and 90-day mortality rates, chyle leakage, RLN palsy as well as cardiac and infectious complication rates. Estimated blood loss (MD - 71.78 mL, p < 0.00001), total number of harvested lymph nodes (MD 2.18 nodes, p < 0.0001) and along the left RLN (MD 0.73 nodes, p = 0.03), pulmonary complications (RR 0.70, p = 0.001) and length of hospital stay (MD - 3.03 days, p < 0.0001) are outcomes that favored RAMIE. A significantly shorter operating time (MD 29.01 min, p = 0.004) and a lower rate of anastomotic leakage (RR 1.23, p = 0.0005) were seen in cMIE. RAMIE has indicated to be a safe and feasible alternative to cMIE, with a tendency towards superiority in blood loss, lymph node yield, pulmonary complications and length of hospital stay. There was significant heterogeneity among studies for some of the outcomes measured. Further studies are necessary to confirm these results and overcome current limitations.
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Affiliation(s)
- Rui Perry
- Faculty of Medicine, University of Porto, Porto, Portugal.
| | - José Pedro Barbosa
- Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Stomatology, São João University Hospital Center, Porto, Portugal
| | - Isabel Perry
- Faculty of Medicine, University of Salamanca, Salamanca, Spain
| | - José Barbosa
- Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of General Surgery, São João University Hospital Center, Porto, Portugal
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5
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Xue M, Liu J, Lu M, Zhang H, Liu W, Tian H. Robotic assisted minimally invasive esophagectomy versus minimally invasive esophagectomy. Front Oncol 2024; 13:1293645. [PMID: 38288099 PMCID: PMC10824560 DOI: 10.3389/fonc.2023.1293645] [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: 09/14/2023] [Accepted: 12/22/2023] [Indexed: 01/31/2024] Open
Abstract
Background Esophagectomy is the gold standard treatment for resectable esophageal cancer; however, there is insufficient evidence to indicate potential advantages over standard minimally invasive esophagectomy (MIE) in treating thoracic esophageal cancer. Robot-assisted minimally invasive esophagectomy (RAMIE) bridges the gap between open and minimally invasive surgery. In this single-center retrospective review, we compare the clinical outcomes of EC patients treated with MIE and RAMIE. Method We retrospectively reviewed the clinical data of patients with esophageal cancer who underwent surgery at Qilu Hospital between August 2020 and August 2022, including 159 patients who underwent MIE and 35 patients who received RAMIE. The intraoperative, postoperative, and preoperative patient characteristics in both groups were evaluated. Results Except for height, the MIE and RAMIE groups showed no significant differences in preoperative features (P>0.05). Further, there were no significant differences in intraoperative indices, including TNM stage of the resected tumor, tumor tissue type, or ASA score, between the two groups. However, statistically significant differences were found in some factors; the RAMIE group had a shorter operative time, less intraoperative bleeding, and more lymph nodes removed compared to the MIE group. Patients in the RAMIE group reported less discomfort and greater chest drainage on the first postoperative day than patients in the MIE group; however, there were no differences in other features between the two datasets. Conclusion By comparing the clinical characteristics and outcomes of RAMIE with MIE, this study verified the feasibility and safety of RAMIE for esophageal cancer. Overall, RAMIE resulted in more complete lymph node clearance, shorter operating time, reduced surgical hemorrhage, reduced postoperative discomfort, and chest drainage alleviation in patients. To investigate the function of RAMIE in esophageal cancer, we propose undertaking a future clinical trial with long-term follow-up to analyze tumor clearance, recurrence, and survival after RAMIE.
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Affiliation(s)
| | | | | | | | | | - Hui Tian
- Department of Thoracic Surgery, Qilu Hospital of Shandong University, Jinan, China
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Hoelzen JP, Frankauer BE, Szardenings C, Roy D, Pollmann L, Fortmann L, Merten J, Rijcken E, Juratli MA, Pascher A. Reducing the Risks of Esophagectomies: A Retrospective Comparison of Hybrid versus Full-Robotic-Assisted Minimally Invasive Esophagectomy (RAMIE) Approaches. J Clin Med 2023; 12:5823. [PMID: 37762765 PMCID: PMC10531670 DOI: 10.3390/jcm12185823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/30/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
This retrospective analysis aimed to assess and compare the short-term perioperative outcomes and morbidity of hybrid and full-Robotic-Assisted Minimally Invasive Esophagectomy (RAMIE) surgical techniques. A total of 168 robotic-assisted Ivor Lewis esophagectomy procedures performed at Muenster University Hospital were included in the study, with 63 cases in the hybrid group and 105 cases in the full-robotic group. Demographic factors, comorbidities, and tumor stages showed no significant differences between the two groups. However, the full-RAMIE technique demonstrated superiority in terms of overall operative time, postoperative pain levels, and patient morphine consumption. Additionally, the full-RAMIE group exhibited better perioperative outcomes, with significantly shorter ICU stays and fewer occurrences of pneumonias and severe complications. While there was a trend favoring the full-RAMIE technique in terms of severe postoperative complications and anastomotic insufficiencies, further research is required to establish it as the gold standard surgical technique for Ivor Lewis esophagectomy.
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Affiliation(s)
- Jens Peter Hoelzen
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, 48149 Muenster, Germany; (B.E.F.); (A.P.)
| | - Brooke E. Frankauer
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, 48149 Muenster, Germany; (B.E.F.); (A.P.)
| | - Carsten Szardenings
- Institute of Biostatistics and Clinical Research, University of Muenster, 48149 Muenster, Germany
| | - Dhruvajyoti Roy
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Lukas Pollmann
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, 48149 Muenster, Germany; (B.E.F.); (A.P.)
| | - Lukas Fortmann
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, 48149 Muenster, Germany; (B.E.F.); (A.P.)
| | - Jennifer Merten
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, 48149 Muenster, Germany; (B.E.F.); (A.P.)
| | - Emile Rijcken
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, 48149 Muenster, Germany; (B.E.F.); (A.P.)
| | - Mazen A. Juratli
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, 48149 Muenster, Germany; (B.E.F.); (A.P.)
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, 48149 Muenster, Germany; (B.E.F.); (A.P.)
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7
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Yu WQ, Zhai LX, Shi GD, Tang JY, Gao HJ, Wei YC. Short-term outcome of totally minimally invasive versus hybrid minimally invasive Ivor-Lewis esophagectomy. Asian J Surg 2023; 46:3727-3733. [PMID: 37085421 DOI: 10.1016/j.asjsur.2023.03.185] [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: 10/11/2022] [Revised: 12/11/2022] [Accepted: 03/31/2023] [Indexed: 04/23/2023] Open
Abstract
OBJECTIVES For resectable esophageal cancer, the choice of total minimally invasive esophagectomy (TMIE) or hybrid minimally invasive esophagectomy (HMIE) remains controversial. The purpose of this study was to evaluate the short-term clinical outcomes of TMIE and HMIE under the Ivor-Lewis procedure. METHODS The data of 145 patients diagnosed with middle or lower esophageal cancer who underwent radical Ivor-Lewis esophagectomy in the Affiliated Hospital of Qingdao University between January 2018 and December 2019 were retrospectively analyzed. The short-term outcomes such as complications during surgery or within 30 days after surgery and postoperative pain were analyzed. RESULTS All patients were divided into TMIE group (75 patients) and HMIE group (70 patients). No significant difference was observed in the baseline characteristics of the two groups. TMIE was associated with less blood loss than the HMIE group (p < 0.05). A total of 54 (37.2%) patients had postoperative complications. Although the two groups were statistically similar in the incidence of major complications, patients in the HMIE group were more likely to have pneumonia compared with those in the TMIE group. The numeric rating scale for pain was significantly higher in the HMIE group (p = 0.002) and more patients required an additional opioid analgesia after esophagectomy (p = 0.282). CONCLUSIONS In conclusion, according to perioperative outcomes, TMIE can benefit patients better than HMIE.
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Affiliation(s)
- Wen-Quan Yu
- Department of Thoracic Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Li-Xue Zhai
- Department of Ultrasonography, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Guo-Dong Shi
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Jia-Yu Tang
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Hui-Jiang Gao
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China.
| | - Yu-Cheng Wei
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China.
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8
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Chan KS, Oo AM. Exploring the learning curve in minimally invasive esophagectomy: a systematic review. Dis Esophagus 2023; 36:doad008. [PMID: 36857586 DOI: 10.1093/dote/doad008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/28/2022] [Accepted: 02/05/2023] [Indexed: 03/03/2023]
Abstract
Minimally invasive esophagectomy (MIE) has been shown to be superior to open esophagectomy with reduced morbidity, mortality, and comparable lymph node (LN) harvest. However, MIE is technically challenging. This study aims to perform a pooled analysis on the number of cases required to surmount the learning curve (LC), i.e. NLC in MIE. PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 2022. Inclusion criteria were articles that reported LC in video-assisted MIE (VAMIE) and/or robot-assisted MIE (RAMIE). Poisson means (95% confidence interval [CI]) was used to determine NLC. Negative binomial regression was used for comparative analysis. There were 41 articles with 45 data sets (n = 7755 patients). The majority of tumors were located in the lower esophagus or gastroesophageal junction (66.7%, n = 3962/5939). The majority of data sets on VAMIE (n = 16/26, 61.5%) used arbitrary analysis, while the majority of data sets (n = 14/19, 73.7%) on RAMIE used cumulative sum control chart analysis. The most common outcomes reported were overall operating time (n = 30/45) and anastomotic leak (n = 28/45). Twenty-four data sets (53.3%) reported on LN harvest. The overall NLC was 34.6 (95% CI: 30.4-39.2), 68.5 (95% CI: 64.9-72.4), 27.5 (95% CI: 24.3-30.9), and 35.9 (95% CI: 32.1-40.2) for hybrid VAMIE, total VAMIE, hybrid RAMIE, and total RAMIE, respectively. NLC was significantly lower for total RAMIE compared to total VAMIE (incidence rate ratio: 0.52, P = 0.032). Studies reporting NLC in MIE are heterogeneous. Further studies should clearly define prior surgical experiences and assess long-term oncological outcomes using non-arbitrary analysis.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Aung Myint Oo
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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9
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Zhang Y, Dong D, Cao Y, Huang M, Li J, Zhang J, Lin J, Sarkaria IS, Toni L, David R, He J, Li H. Robotic Versus Conventional Minimally Invasive Esophagectomy for Esophageal Cancer: A Meta-analysis. Ann Surg 2023; 278:39-50. [PMID: 36538615 DOI: 10.1097/sla.0000000000005782] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Yajie Zhang
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dong Dong
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuqin Cao
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Maosheng Huang
- Department of Epidemiology, University of Texas MD Anderson Cancer Center, Houston TX
| | - Jian Li
- Clinical Research Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiahao Zhang
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jules Lin
- Section of Thoracic Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Inderpal S Sarkaria
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Lerut Toni
- Department of Thoracic Surgery, University Hospital Leuven, Leuven, Belgium
| | - Rice David
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jie He
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hecheng Li
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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10
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Pickering OJ, van Boxel GI, Carter NC, Mercer SJ, Knight BC, Pucher PH. Learning curve for adoption of robot-assisted minimally invasive esophagectomy: a systematic review of oncological, clinical, and efficiency outcomes. Dis Esophagus 2023; 36:6961031. [PMID: 36572404 DOI: 10.1093/dote/doac089] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/25/2022] [Indexed: 05/30/2023]
Abstract
BACKGROUND Robot-assisted minimally invasive esophagectomy (RAMIE) is gaining increasing popularity as an operative approach. Learning curves to achieve surgical competency in robotic-assisted techniques have shown significant variation in learning curve lengths and outcomes. This study aimed to summarize the current literature on learning curves for RAMIE. METHODS A systematic review was conducted in line with PRISMA guidelines. Electronic databases PubMed, MEDLINE, and Cochrane Library were searched, and articles reporting on learning curves in RAMIE were identified and scrutinized. Studies were eligible if they reported changes in operative outcomes over time, or learning curves, for surgeons newly adopting RAMIE. RESULTS Fifteen studies reporting on 1767 patients were included. Nine studies reported on surgeons with prior experience of robot-assisted surgery prior to adopting RAMIE, with only four studies outlining a specified RAMIE adoption pathway. Learning curves were most commonly analyzed using cumulative sum control chart (CUSUM) and were typically reported for lymph node yields and operative times, with significant variation in learning curve lengths (18-73 cases and 20-80 cases, respectively). Most studies reported adoption without significant impact on clinical outcomes such as anastomotic leak; significant learning curves were more likely in studies, which did not report a formal learning or adoption pathway. CONCLUSION Reported RAMIE adoption phases are variable, with some authors suggesting significant impact to patients. With robust training through formal programmes or proctorship, however, others report RAMIE adoption without impact on clinical outcomes. A formalized adoption curriculum appears critical to prevent adverse effects on operative efficiency and patient care.
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Affiliation(s)
- Oliver J Pickering
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Gijs I van Boxel
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Nick C Carter
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Stuart J Mercer
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Benjamin C Knight
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Philip H Pucher
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
- Department of Pharmacology and Biosciences, University of Portsmouth, Portsmouth, UK
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11
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Froiio C, Uzun E, Hadzijusufovic E, Capovilla G, Berlth F, Lang H, Grimminger PP. Semiprone thoracoscopic approach during totally minimally invasive Ivor-Lewis esophagectomy seems to be beneficial. Dis Esophagus 2023; 36:6627608. [PMID: 35780319 DOI: 10.1093/dote/doac044] [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: 03/20/2022] [Revised: 05/24/2022] [Accepted: 06/13/2022] [Indexed: 02/01/2023]
Abstract
Minimally invasive Ivor-Lewis Esophagectomy (MIE) is widely accepted as a surgical treatment of resectable esophageal cancer. Aim of this paper is to describe the surgical details of our standardized MIE technique and its safety. We also evaluate the esophageal mobilization in semiprone compared to the left lateral position. A retrospective analysis of 141 consecutive patients who underwent Ivor-Lewis esophagectomy for cancer, from February 2016 to September 2021, was conducted. All the procedures were performed by totally thoraco-laparoscopic with an intrathoracic end-to-side circular stapled anastomosis. Thoracic phase was performed in left lateral position (LLP-group, n=47) followed by a semiprone position (SP-group, n=94). The intraoperative and postoperative outcomes were prospectively collected and analyzed. The procedure was completed without intraoperative complication in 94.68% of cases in SP-group and in 93.62% of cases in LLP-group (P=0.99). The total operative time and thoracic operative time were significantly shorter in SP-group (P=0.0096; P=0.009). No statistically significant differences were detected in postoperative outcomes between the groups, except for anastomotic strictures (higher in LLP-group, P=0.02) and intensive care unit stay (longer in LLP-group, P=00.1). No reoperation was needed in any cases. Surgical radicality was comparable; the median of harvested lymph nodes was significantly higher in SP-group (P<0.0001). The present semiprone technique of thoraco-laparoscopic Ivor-Lewis esophagectomy is safe and feasible but may also provide some advantages in terms of lymph nodes harvested and total operation time.
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Affiliation(s)
- Caterina Froiio
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany.,Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese, Milano, Italy
| | - Eren Uzun
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany
| | - Edin Hadzijusufovic
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany
| | - Giovanni Capovilla
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany
| | - Felix Berlth
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany
| | - Peter P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany
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12
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Hoelzen JP, Sander KJ, Sesia M, Roy D, Rijcken E, Schnabel A, Struecker B, Juratli MA, Pascher A. Robotic-Assisted Esophagectomy Leads to Significant Reduction in Postoperative Acute Pain: A Retrospective Clinical Trial. Ann Surg Oncol 2022; 29:7498-7509. [PMID: 35854033 PMCID: PMC9550779 DOI: 10.1245/s10434-022-12200-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/25/2022] [Indexed: 12/24/2022]
Abstract
Background Robot-assisted minimally invasive esophagectomy (RAMIE) shows promising results regarding postoperative complications in patients with esophageal cancer. To date, no data are available regarding postoperative analgesic consumption. The aim of this work is to evaluate analgesic consumption after esophagectomy. Methods A total of 274 Ivor Lewis esophageal resections performed sequentially from January 2012 to December 2020 were evaluated. RAMIE cases (n = 51) were compared with the hybrid technique (laparoscopic abdominal phase followed by open thoracotomy, n = 59) and open abdominothoracic esophagectomy (OTE) (n = 164). Data were collected retrospectively. The primary endpoint was the overall postoperative morphine consumption, which represents a reliable indirect measurement of pain. Pain levels recorded on the first, third, and fifth postoperative days were assessed as secondary endpoints. Results A total of 274 patients were included. The postoperative opioid consumption rate for patients who underwent RAMIE (quartiles: 0.14, 0.23, 0.36 mg morphine milligram equivalents (MME)/kg body weight (bw)/day) was significantly lower than in the open group (0.19, 0.33, 0.58 mg MME/kg bw/day, p = 0.016). The overall postoperative opioid consumption for patients who underwent RAMIE was significantly lower (2.45, 3.63, 7.20 mg MME/kg bw/day; morphine milligram equivalents per kilogram body weight) compared with the open (4.85, 8.59, 14.63 MME/kg bw/day, p < 0.0001) and hybrid (4.13, 6.84, 11.36 MME/kg bw/day, p = 0.008) groups. Patients who underwent RAMIE reported lower pain scores compared with the open group on the fifth postoperative day, both at rest (p = 0.004) and while performing activities (p < 0.001). Conclusions This study shows that patients who underwent RAMIE experienced similar postoperative pain while requiring significantly lower amounts of opioids compared with patients who underwent open and hybrid surgery. Further studies are required to verify the results.
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Affiliation(s)
- Jens P Hoelzen
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany.
| | - Karl J Sander
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
| | - Matteo Sesia
- Department of Data Sciences and Operations, Marshall School of Business, University of Southern California, Los Angeles, CA, USA
| | | | - Emile Rijcken
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
| | - Alexander Schnabel
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Benjamin Struecker
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
| | - Mazen A Juratli
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
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13
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Fuchs HF, Collins JW, Babic B, DuCoin C, Meireles OR, Grimminger PP, Read M, Abbas A, Sallum R, Müller-Stich BP, Perez D, Biebl M, Egberts JH, van Hillegersberg R, Bruns CJ. Robotic-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer training curriculum-a worldwide Delphi consensus study. Dis Esophagus 2022; 35:6348318. [PMID: 34382061 DOI: 10.1093/dote/doab055] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/29/2021] [Accepted: 07/23/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Structured training protocols can safely improve skills prior initiating complex surgical procedures such as robotic-assisted minimally invasive esophagectomy (RAMIE). As no consensus on a training curriculum for RAMIE has been established so far it is our aim to define a protocol for RAMIE with the Delphi consensus methodology. METHODS Fourteen worldwide RAMIE experts were defined and were enrolled in this Delphi consensus project. An expert panel was created and three Delphi rounds were performed starting December 2019. Items required for RAMIE included, but were not limited to, virtual reality simulation, wet-lab training, proctoring, and continued monitoring and education. After rating performed by the experts, consensus was defined when a Cronbach alpha of ≥0.80 was reached. If ≥80% of the committee reached a consensus an item was seen as fundamental. RESULTS All Delphi rounds were completed by 12-14 (86-100%) participants. After three rounds analyzing our 49-item questionnaire, 40 items reached consensus for a training curriculum of RAMIE. CONCLUSION The core principles for RAMIE training were defined. This curriculum may lead to a wider adoption of RAMIE and a reduction in time to reach proficiency.
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Affiliation(s)
- Hans F Fuchs
- Department of General, Visceral, Cancer, and Transplantation Surgery, University of Cologne, Cologne, Germany
| | | | - Benjamin Babic
- Department of General, Visceral, Cancer, and Transplantation Surgery, University of Cologne, Cologne, Germany
| | | | | | | | | | | | | | | | - Daniel Perez
- Department of Surgery, University of Hamburg, Hamburg, Germany
| | | | | | | | - Christiane J Bruns
- Department of General, Visceral, Cancer, and Transplantation Surgery, University of Cologne, Cologne, Germany
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14
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Babic B, Müller DT, Jung JO, Schiffmann LM, Grisar P, Schmidt T, Chon SH, Schröder W, Bruns CJ, Fuchs HF. Robot-assisted minimally invasive esophagectomy (RAMIE) vs. hybrid minimally invasive esophagectomy: propensity score matched short-term outcome analysis of a European high-volume center. Surg Endosc 2022; 36:7747-7755. [PMID: 35505259 PMCID: PMC9485091 DOI: 10.1007/s00464-022-09254-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 04/08/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Transthoracic esophagectomy is a highly complex and sophisticated procedure with high morbidity rates and a significant mortality. Surgical access has consistently become less invasive, transitioning from open esophagectomy to hybrid esophagectomy (HE) then to totally minimally invasive esophagectomy (MIE), and most recently to robot-assisted minimally invasive esophagectomy (RAMIE), with each step demonstrating improved patient outcomes. Aim of this study with more than 600 patients is to complete a propensity-score matched comparison of postoperative short-term outcomes after highly standardized RAMIE vs. HE in a European high volume center. PATIENTS AND METHODS Six hundred and eleven patients that underwent transthoracic Ivor-Lewis esophagectomy for esophageal cancer between May 2016 and May 2021 were included in the study. In January 2019, we implemented an updated robotic standardized anastomotic technique using a circular stapler and ICG (indocyanine green) for RAMIE cases. Data were retrospectively analyzed from a prospectively maintained IRB-approved database. Outcomes of patients undergoing standardized RAMIE from January 2019 to May 2021 were compared to our overall cohort from May 2016-April 2021 (HE) after a propensity-score matching analysis was performed. RESULTS Six hundred and eleven patients were analyzed. 107 patients underwent RAMIE. Of these, a total of 76 patients underwent a robotic thoracic reconstruction using the updated standardized circular stapled anastomosis (RAMIE group). A total of 535 patients underwent HE (Hybrid group). Seventy patients were propensity-score matched in each group and analysis revealed no statistically significant differences in baseline characteristics. RAMIE patients had a significantly shorter ICU stay (p = 0.0218). Significantly more patients had no postoperative complications (Clavien Dindo 0) in the RAMIE group [47.1% vs. 27.1% in the HE group (p = 0.0225)]. No difference was seen in lymph node yield and R0 resection rates. Anastomotic leakage rates when matched were 14.3% in the hybrid group vs. 4.3% in the RAMIE group (p = 0.07). CONCLUSION Our analysis confirms the safety and feasibility of RAMIE and HE in a large cohort after propensity score matching. A regular postoperative course (Clavien-Dindo 0) and a shorter ICU stay were seen significantly more often after RAMIE compared to HE. Furthermore it shows that both procedures provide excellent short-term oncologic outcomes, regarding lymph node harvest and R0 resection rates. A randomized controlled trial comparing RAMIE and HE is still pending and will hopefully contribute to ongoing discussions.
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Affiliation(s)
- Benjamin Babic
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany.
| | - Dolores T Müller
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Jin-On Jung
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Lars M Schiffmann
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Paula Grisar
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Thomas Schmidt
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Wolfgang Schröder
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Christiane J Bruns
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Hans F Fuchs
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
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15
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Completely minimally invasive versus hybrid Ivor-Lewis oesophagectomy for oesophageal and gastro-oesophageal junctional cancer: a UK multi-centre comparative study. Surg Endosc 2022; 36:5822-5832. [PMID: 35044515 DOI: 10.1007/s00464-022-09043-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 01/09/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Limited robust evidence exists comparing outcomes following completely minimally invasive oesophagectomy (CMIO) to hybrid oesophagectomy (HO) in the treatment of resectable oesophageal and gastro-oesophageal junctional (GOJ) cancer. This multi-centre study aims to assess postoperative morbidity between HO and CMIO according to the full Esophagectomy Complications Consensus Group (ECCG) complication platform. METHODS All consecutive patients undergoing an Ivor-Lewis HO or Ivor-Lewis CMIO for cancer between 2016 and 2018 in three UK tertiary centres were included. The primary study outcome was 30-day overall complications, evaluated by the ECCG complication subgroups. Secondary outcomes included survival outcomes and perioperative parameters between the two approaches. RESULTS Of the 382 patients included, 228 (59.7%) patients had HOs and 154 (40.3%) patients had CMIOs with no inter-group baseline differences. Patients undergoing CMIO experienced less 30-day postoperative complications compared to those under undergoing HO (43.5% vs 57.0%, p = 0.010). ECCG defined pulmonary and infective complications were less frequent in the CMIO group. Anastomotic leak rates and oncological outcomes were similar between the two groups. Independent predictors of 30-day postoperative complications include surgical approach with HO and high ASA grade on multivariable analysis. CONCLUSIONS Ivor-Lewis CMIO demonstrates superior short-term surgical outcomes when compared to Ivor-Lewis HO with no compromise in oncological feasibility. Anastomotic leak rates were equivalent between both groups. A robust randomised controlled trial is required to validate the findings of this study.
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16
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Harriott CB, Angeramo CA, Casas MA, Schlottmann F. Open vs. Hybrid vs. Totally Minimally Invasive Ivor Lewis Esophagectomy: Systematic Review and Meta-analysis. J Thorac Cardiovasc Surg 2022; 164:e233-e254. [DOI: 10.1016/j.jtcvs.2021.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/03/2021] [Accepted: 12/24/2021] [Indexed: 02/07/2023]
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17
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Nuytens F, Lenne X, Clément G, Bruandet A, Eveno C, Piessen G. Effect of Phased Implementation of Totally Minimally Invasive Ivor Lewis Esophagectomy for Esophageal Cancer after Previous Adoption of the Hybrid Minimally Invasive Technique: Results from a French Nationwide Population-Based Cohort Study. Ann Surg Oncol 2021; 29:2791-2801. [PMID: 34837133 DOI: 10.1245/s10434-021-11110-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/01/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Several randomized controlled trials (RCTs) have demonstrated improved short-term outcomes of totally minimally invasive esophagectomy (TMIE) compared with open esophagectomy (OE); however, to what extent these outcomes can be extrapolated to a national level remains debatable. OBJECTIVE The aim of this study was to evaluate, on a nationwide basis, the short-term outcomes of TMIE and to analyze these results within the context of previously implemented hybrid minimally invasive esophagectomy (HMIE). METHODS All consecutive patients who underwent a curative Ivor Lewis esophagectomy in France between 2017 and 2019 were included in this retrospective cohort study. The primary endpoint was to compare 90-day postoperative mortality (POM) between OE, HMIE, and TMIE, while secondary endpoints were defined as the rate of postoperative complications. A matched and multivariate analysis was adjusted for confounding factors. RESULTS Overall, 2675 patients were included (1003 OE vs. 1498 HMIE vs. 174 TMIE). In every center where TMIE was performed, HMIE had been previously adopted. The matched 90-day POM rate in the TMIE group was significantly lower compared with the OE group (2.3% vs. 6.3%, p = 0.046) but not compared with the HMIE group (2.3% vs. 4.9%, p = 0.156). There was no significant difference between TMIE and OE, or TMIE and HMIE, regarding the 30-day fistula rate (21.8% vs. 17%, p = 0.176; and 21.8% vs. 21.3%, p = 0.88, respectively). TMIE was associated with a reduced rate of pulmonary complications compared with OE (33.9% vs. 44%, p = 0.027) and HMIE (33.9% vs. 42.8%, p = 0.05). Low-volume centers were identified as a negative predictive factor for 90-day POM (odds ratio 1.89, 95% confidence interval 1.3-2.75, p = 0.001). CONCLUSION TMIE is associated with a lower 90-day POM rate compared with OE and offers reduced rates of pulmonary complications compared with OE and HMIE. After previous adoption of the HMIE technique, TMIE can be safely implemented in high-volume centers nationwide.
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Affiliation(s)
- Frederiek Nuytens
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, University Lille, Lille, France. .,Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge Hospital, Kortrijk, Belgium.
| | - Xavier Lenne
- Medical Information Department, Lille University Hospital, Lille, France.,ULR 2694 - METRICS: Evaluation des technologies de sante et des pratiques médicales, University Lille, CHU Lille, Lille, France
| | - Guillaume Clément
- Medical Information Department, Lille University Hospital, Lille, France
| | - Amelie Bruandet
- Medical Information Department, Lille University Hospital, Lille, France.,ULR 2694 - METRICS: Evaluation des technologies de sante et des pratiques médicales, University Lille, CHU Lille, Lille, France
| | - Clarisse Eveno
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, University Lille, Lille, France.,UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University Lille, CNRS, Inserm, CHU Lille, Lille, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, University Lille, Lille, France.,UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University Lille, CNRS, Inserm, CHU Lille, Lille, France
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18
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Chen H, Liu Y, Peng H, Wang R, Wang K, Li D. Robot-assisted minimally invasive esophagectomy versus video-assisted minimally invasive esophagectomy: a systematic review and meta-analysis. Transl Cancer Res 2021; 10:4601-4616. [PMID: 35116317 PMCID: PMC8798469 DOI: 10.21037/tcr-21-1482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/14/2021] [Indexed: 12/25/2022]
Abstract
Background Robot-assisted minimally invasive esophagectomy (RAMIE) has been demonstrated to offer realistic three-dimensional visual clarity, flexible movement and so on. The high cost is the main reason hampering universal application. The aim of this study was to compare the short-term outcomes of RAMIE versus video-assisted minimally invasive esophagectomy (VAMIE). Methods The PubMed, EMBASE and Web of Science databases were systematically searched up to June 1, 2021, for studies comparing RAMIE and VAMIE. Results Nineteen studies were enrolled, which consisted of a total of 4,714 patients, including 2,306 patients in the RAMIE group and 2,408 patients in the VAMIE group. In RAMIE patients, higher numbers of total lymph nodes (MD =0.171, 95% CI: 0.086–0.255, P<0.001) and lymph nodes along the left recurrent laryngeal nerve (RLN) (MD =0.219, 95% CI: 0.097–0.340, P<0.001) were removed. In RAMIE patients in the McKown group, higher numbers of total lymph nodes (MD =0.173, 95% CI: 0.080–0.265, P<0.001) and lymph nodes along the left RLN (MD =0.220, 95% CI: 0.090–0.350, P=0.001) were removed, while in those in the ESCC group, higher numbers of total lymph nodes (MD =0.249, 95% CI: 0.091–0.407, P=0.002) and lymph nodes along the left RLN (MD =0.239, 95% CI: 0.102–0.377, P=0.001) were removed. Discussion This study indicated that the main advantage of RAMIE was a greater number of harvested lymph nodes, which may be beneficial to diagnosis and local control. RCTs with larger sample sizes and studies reporting long-term outcomes are needed to evaluate the advantages and disadvantages of RAMIE and VAMIE.
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Affiliation(s)
- Hao Chen
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Yiyang Liu
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Hao Peng
- Department of Cardiothoracic Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Rongchun Wang
- Department of Cardiothoracic Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Kang Wang
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Demin Li
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
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19
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Angeramo CA, Bras Harriott C, Casas MA, Schlottmann F. Minimally invasive Ivor Lewis esophagectomy: Robot-assisted versus laparoscopic-thoracoscopic technique. Systematic review and meta-analysis. Surgery 2021; 170:1692-1701. [PMID: 34389164 DOI: 10.1016/j.surg.2021.07.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/06/2021] [Accepted: 07/12/2021] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
| | | | - María A Casas
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
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20
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Manigrasso M, Vertaldi S, Marello A, Antoniou SA, Francis NK, De Palma GD, Milone M. Robotic Esophagectomy. A Systematic Review with Meta-Analysis of Clinical Outcomes. J Pers Med 2021; 11:jpm11070640. [PMID: 34357107 PMCID: PMC8306060 DOI: 10.3390/jpm11070640] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/22/2021] [Accepted: 07/01/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Robot-Assisted Minimally Invasive Esophagectomy is demonstrated to be related with a facilitation in thoracoscopic procedure. To give an update on the state of art of robotic esophagectomy for cancr a systematic review with meta-analysis has been performed. Methods: a search of the studies comparing robotic and laparoscopic or open esophagectomy was performed trough the medical libraries, with the search string “robotic and (oesophagus OR esophagus OR esophagectomy OR oesophagectomy)”. Outcomes were: postoperative complications rate (anastomotic leakage, bleeding, wound infection, pneumonia, recurrent laryngeal nerves paralysis, chylotorax, mortality), intraoperative outcomes (mean blood loss, operative time and conversion), oncologic outcomes (harvested nodes, R0 resection, recurrence) and recovery outcomes (length of hospital stay). Results: Robotic approach is superior to open surgery in terms of blood loss p = 0.001, wound infection rate, p = 0.002, pneumonia rate, p = 0.030 and mean number of harvested nodes, p < 0.0001 and R0 resection rate, p = 0.043. Similarly, robotic approach is superior to conventional laparoscopy in terms of mean number of harvested nodes, p = 0.001 pneumonia rate, p = 0.003. Conclusions: robotic surgery could be considered superior to both open surgery and conventional laparoscopy. These encouraging results should promote the diffusion of the robotic surgery, with the creation of randomized trials to overcome selection bias.
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Affiliation(s)
- Michele Manigrasso
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy;
| | - Sara Vertaldi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (A.M.); (G.D.D.P.)
| | - Alessandra Marello
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (A.M.); (G.D.D.P.)
| | - Stavros Athanasios Antoniou
- Medical School, European University Cyprus, 2404 Nicosia, Cyprus;
- Department of Surgery, Mediterranean Hospital of Cyprus, 3117 Limassol, Cyprus
| | | | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (A.M.); (G.D.D.P.)
| | - Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (A.M.); (G.D.D.P.)
- Correspondence: ; Tel.: +39-333-299-36-37
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21
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de Groot EM, Goense L, Ruurda JP, van Hillegersberg R. State of the art in esophagectomy: robotic assistance in the abdominal phase. Updates Surg 2020; 73:823-830. [PMID: 33382446 PMCID: PMC8184533 DOI: 10.1007/s13304-020-00937-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/07/2020] [Indexed: 12/15/2022]
Abstract
Over the years, robot-assisted esophagectomy gained popularity. The current literature focused mainly on robotic assistance in the thoracic phase, whereas the implementation of robotic assistance in the abdominal phase is lagging behind. Advantages of adding a robotic system to the abdominal phase include robotic stapling and the increased surgeon's independency. In terms of short-term outcomes and lymphadenectomy, robotic assistance is at least equal to laparoscopy. Yet high quality evidence to conclude on this topic remains scarce. This review focuses on the evidence of robotic assistance in the abdominal phase of esophagectomy.
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Affiliation(s)
- Eline M de Groot
- Department of Surgery, University Medical Center Utrecht, POBOX 85500, 3508 GA, Utrecht, The Netherlands.
| | - Lucas Goense
- Department of Surgery, University Medical Center Utrecht, POBOX 85500, 3508 GA, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, POBOX 85500, 3508 GA, Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, POBOX 85500, 3508 GA, Utrecht, The Netherlands.
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22
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Kingma BF, Hadzijusufovic E, Van der Sluis PC, Bano E, Lang H, Ruurda JP, Hillegersberg van R, Grimminger PP. A structured training pathway to implement robot-assisted minimally invasive esophagectomy: the learning curve results from a high-volume center. Dis Esophagus 2020; 33:5843553. [PMID: 33241300 DOI: 10.1093/dote/doaa047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/23/2020] [Accepted: 04/28/2020] [Indexed: 12/11/2022]
Abstract
To ensure safe implementation of robot-assisted minimally invasive esophagectomy (RAMIE), the learning process should be optimized. This study aimed to report the results of a surgeon who implemented RAMIE in a German high-volume center by following a tailored and structured training pathway that involved proctoring. Consecutive patients who underwent RAMIE during the course of the program were included from a prospective database. A single surgeon, who had prior experience in conventional MIE, performed all RAMIE procedures. Cumulative sum (CUSUM) learning curves were plotted for the thoracic operating time and intraoperative blood loss. Perioperative outcomes were compared between patients who underwent surgery before and after a learning curve plateau occurred. Between 2017 and 2018, the adopting center adhered to the structured training pathway, and a total of 70 patients were included in the analysis. The CUSUM learning curves showed plateaus after 22 cases. In consecutive cases 23 to 70, the operating time was shorter for both the thoracic phase (median 215 vs. 249 minutes, P = 0.001) and overall procedure (median 394 vs. 440 minutes, P = 0.005), intraoperative blood loss was less (median 210 vs. 400 milliliters, P = 0.029), and lymph node yield was higher (median 32 vs. 23 nodes, P = 0.001) when compared to cases 1 to 22. No significant differences were found in terms of conversion rates, postoperative complications, length of stay, completeness of resection, or mortality. In conclusion, the structured training pathway resulted in a short and safe learning curve for RAMIE in this single center's experience. As the pathway seems effective in implementing RAMIE without compromising the early oncological outcomes and complication rates, it is advised for surgeons who are wanting to adopt this technique.
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Affiliation(s)
- B Feike Kingma
- University Medical Center Utrecht, Department of Surgery, Utrecht University, Utrecht, The Netherlands
| | - Edin Hadzijusufovic
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Pieter C Van der Sluis
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Erida Bano
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Jelle P Ruurda
- University Medical Center Utrecht, Department of Surgery, Utrecht University, Utrecht, The Netherlands
| | - Richard Hillegersberg van
- University Medical Center Utrecht, Department of Surgery, Utrecht University, Utrecht, The Netherlands
| | - Peter P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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Abstract
Summary
Background
In the surgical treatment of esophageal cancer, complete tumor resection is the most important factor and determines long-term survival. With an increase in robotic expertise in other fields of surgery, robotic-assisted minimally invasive esophagectomy (RAMIE) was born. Currently, there is a lack of convincing data on the extent of expected benefits (perioperative and oncologic outcomes and/or quality of life). Some evidence exists that patients’ overall quality of life and physical function improves, with less fatigue and pain 3 months after surgery. We aimed to review the available literature regarding robotic esophagectomy, compare perioperative, oncologic, and quality of life outcomes with open and minimally invasive approaches, and give a brief overview of our standardized four-arm RAMIE technique and explore future directions.
Methods
A Medline (PubMed) search was conducted including the following key words: esophagectomy, minimally invasive esophagectomy, robotic esophagectomy, Ivor Lewis and McKeown. We present the history, different techniques used, outcomes, and the standardization of robotic esophagectomy.
Results
Robotic esophagectomy offers a steeper learning curve with fewer complications but comparable oncological results compared to conventional minimally invasive esophagectomy.
Conclusions
Available studies suggest that RAMIE is associated with benefits regarding length of stay, clinical outcomes, and quality of life—if patients are treated in an experienced center with a standardized technique for robotic esophagectomy—making it a potentially beneficial tool in the treatment of esophageal cancer. However, center-wide standardization and prospective data collection will be a necessity to prove superiority of robotic esophagectomy.
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Patel K, Abbassi O, Tang CB, Lorenzi B, Charalabopoulos A, Kadirkamanathan S, Jayanthi NV. Completely Minimally Invasive Esophagectomy Versus Hybrid Esophagectomy for Esophageal and Gastroesophageal Junctional Cancer: Clinical and Short-Term Oncological Outcomes. Ann Surg Oncol 2020; 28:702-711. [PMID: 32648175 DOI: 10.1245/s10434-020-08826-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 06/24/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Minimally invasive surgery for resectable esophageal and gastroesophageal junctional (GEJ) cancer significantly reduces morbidity when compared with open surgery, as is evident from published landmark trials. Comparison of outcomes between hybrid esophagectomy (HE) and completely minimally invasive esophagectomy (CMIE) remains unclear. OBJECTIVE We aimed to ascertain whether CMIE is associated with less postoperative complications compared with HE without oncological compromise. METHODS All consecutive two-stage HEs and CMIEs performed between 2016 and 2018 were included. All procedures were performed with an intrathoracic anastomosis. Primary clinical outcomes were pulmonary infective and overall complications within 30 days of surgery, while primary oncological outcomes included overall survival (OS) and disease-free survival (DFS) at both 6 months and to date. Secondary outcomes included intraoperative variables and postoperative clinical parameters. RESULTS Overall, 98 patients had CMIEs and 49 patients had HEs. There were no baseline differences between the two groups. Thirty-day postoperative pulmonary infection rates were lower in the CMIE group compared with the HE group (12.2% vs. 28.6%; p = 0.014), and 30-day overall postoperative complication rates were also lower following CMIE (35.7% vs. 59.2%; p = 0.007). OS and DFS were similar between the two groups at 6 months (p = 0.201 and p = 0.109, respectively). CONCLUSIONS CMIE is associated with less pulmonary infective and overall postoperative complications compared with HE for resectable esophageal and GEJ cancer. No intergroup difference was observed regarding short-term survival and cancer recurrence in patients undergoing CMIE and HE. A randomized controlled trial comparing the two operative approaches is required to validate these findings.
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Affiliation(s)
- Krashna Patel
- Essex Upper GI, Regional Centre for Oesophagogastric Surgery, Broomfield Hospital, Chelmsford, UK.
| | - Omar Abbassi
- Essex Upper GI, Regional Centre for Oesophagogastric Surgery, Broomfield Hospital, Chelmsford, UK
| | - Cheuk Bong Tang
- Essex Upper GI, Regional Centre for Oesophagogastric Surgery, Broomfield Hospital, Chelmsford, UK
| | - Bruno Lorenzi
- Essex Upper GI, Regional Centre for Oesophagogastric Surgery, Broomfield Hospital, Chelmsford, UK
| | | | | | - Naga Venkatesh Jayanthi
- Essex Upper GI, Regional Centre for Oesophagogastric Surgery, Broomfield Hospital, Chelmsford, UK
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Seto Y. Essential Updates 2018/2019: Essential Updates for esophageal cancer surgery. Ann Gastroenterol Surg 2020; 4:190-194. [PMID: 32490332 PMCID: PMC7240138 DOI: 10.1002/ags3.12319] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 01/17/2020] [Accepted: 01/22/2020] [Indexed: 02/06/2023] Open
Abstract
Key papers to treatment of esophageal cancer surgery and reduction of postoperative complications after esophagectomy published between 2018 and 2019 were reviewed. Within this review there was a focus on minimally invasive esophagectomy (MIE), robot-assisted MIE (RAMIE), and centralization to high-volume center. Advantages of MIE, irrespectively of hybrid or total MIE, to prevent postoperative complications, especially pneumonia, were shown in comparison to open procedure. However, whether total MIE has evident effects or not, as compared to hybrid MIEs, still remains unclear. Differences between RAMIE and MIE were reported to be marginal, though the advantage of lymphadenectomy, especially along recurrent laryngeal nerve, has been suggested. Centralization to high-volume center evidently benefits esophageal cancer patients by improving short-term outcomes. The definition of high-volume center has not been established yet, though institutional structure and quality are thought to be important. Transmediastinal esophagectomy, currently developed, has a potential to be one radical option of MIE for esophageal cancer.
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Affiliation(s)
- Yasuyuki Seto
- Department of Gastrointestinal Surgery Graduate School of Medicine The University of Tokyo Tokyo Japan
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van Workum F, Klarenbeek BR, Baranov N, Rovers MM, Rosman C. Totally minimally invasive esophagectomy versus hybrid minimally invasive esophagectomy: systematic review and meta-analysis. Dis Esophagus 2020; 33:5827029. [PMID: 32350519 PMCID: PMC7455468 DOI: 10.1093/dote/doaa021] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/27/2020] [Accepted: 03/23/2020] [Indexed: 02/07/2023]
Abstract
Minimally invasive esophagectomy is increasingly performed for the treatment of esophageal cancer, but it is unclear whether hybrid minimally invasive esophagectomy (HMIE) or totally minimally invasive esophagectomy (TMIE) should be preferred. The objective of this study was to perform a meta-analysis of studies comparing HMIE with TMIE. A systematic literature search was performed in MEDLINE, Embase, and the Cochrane Library. Articles comparing HMIE and TMIE were included. The Newcastle-Ottawa scale was used for critical appraisal of methodological quality. The primary outcome was pneumonia. Sensitivity analysis was performed by analyzing outcome for open chest hybrid MIE versus total TMIE and open abdomen MIE versus TMIE separately. Therefore, subgroup analysis was performed for laparoscopy-assisted HMIE versus TMIE, thoracoscopy-assisted HMIE versus TMIE, Ivor Lewis HMIE versus Ivor Lewis TMIE, and McKeown HMIE versus McKeown TMIE. There were no randomized controlled trials. Twenty-nine studies with a total of 3732 patients were included. Studies had a low to moderate risk of bias. In the main analysis, the pooled incidence of pneumonia was 19.0% after HMIE and 9.8% after TMIE which was not significantly different between the groups (RR: 1.46, 95% CI: 0.97-2.20). TMIE was associated with a lower incidence of wound infections (RR: 1.81, 95% CI: 1.13-2.90) and less blood loss (SMD: 0.78, 95% CI: 0.34-1.22) but with longer operative time (SMD:-0.33, 95% CI: -0.59--0.08). In subgroup analysis, laparoscopy-assisted HMIE was associated with a higher lymph node count than TMIE, and Ivor Lewis HMIE was associated with a lower anastomotic leakage rate than Ivor Lewis TMIE. In general, TMIE was associated with moderately lower morbidity compared to HMIE, but randomized controlled evidence is lacking. The higher leakage rate and lower lymph node count that was found after TMIE in sensitivity analysis indicate that TMIE can also have disadvantages. The findings of this meta-analysis should be considered carefully by surgeons when moving from HMIE to TMIE.
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Affiliation(s)
- Frans van Workum
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands,Address correspondence to: Frans van Workum, Radboud University Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | | | - Nikolaj Baranov
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
| | - Maroeska M Rovers
- Department of Health Evidence and Operating Rooms, Radboudumc, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
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Fuchs HF, Müller DT, Leers JM, Schröder W, Bruns CJ. Modular step-up approach to robot-assisted transthoracic esophagectomy-experience of a German high volume center. Transl Gastroenterol Hepatol 2019; 4:62. [PMID: 31559343 DOI: 10.21037/tgh.2019.07.04] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 07/11/2019] [Indexed: 01/26/2023] Open
Abstract
Background The use of robotic technology in general surgery is rapidly increasing in Europe. Aim of this study is to evaluate the introduction of new robotic technologies in a center of excellence for upper gastrointestinal surgery. Methods A standardized teaching protocol of a complete OR team was performed in simulation and animal models at the Center for the Future of Surgery (San Diego CA, USA) and IRCAD (Strasbourg, France) to receive certification as console surgeons. Starting 02/2017 the daVinci Xi and Stryker ICG laparoscopy systems were introduced at our academic center (certified center of excellence for surgery of the upper gastrointestinal tract, n>300 upper gastrointestinal cases/year). After simple training procedures based on our minimally invasive expertise were performed, difficulty was increased based on a modular step up approach to finally perform robotic assisted transthoracic Ivor Lewis esophagectomy. Results A total of 70 patients (9 females) fulfilled inclusion criteria to our study. Robotic assisted esophagectomy was divided into six modules. Level of difficulty was increased based on our modular step up approach without quality compromises. There were no intraoperative complications and no unplanned conversions to open surgery. Two surgeons were able to sequentially train and perform a completely robotic transthoracic esophagectomy using this modular approach without a substantial learning curve. A total of ten esophagectomies per surgeon were necessary to complete all modules in one case. Conclusions The standardized training protocol and the University of Cologne modular step up approach allowed safe introduction of the new technology used. All cases were performed safely without operation-associated complications.
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Affiliation(s)
- Hans F Fuchs
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - Dolores T Müller
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - Jessica M Leers
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - Wolfgang Schröder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - Christiane J Bruns
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
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