Outcomes of robotic-assisted transhiatal esophagectomy for esophageal cancer after neoadjuvant chemoradiation

Is Robotic Surgery the Future for Resectable Esophageal Cancer?: A Systematic Literature Review of Oncological and Clinical Outcomes

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.

Evaluating the Cost for Robotic vs "Non-Robotic" Transhiatal Esophagectomy

INTRODUCTION

This study was undertaken to analyze and compare the cost of robotic transhiatal esophagectomy (THE) to "non-robotic" THE (ie, "open" and laparoscopic).

METHODS

With IRB approval, we prospectively followed 82 patients who underwent THE. We analyzed clinical outcomes and perioperative charges and costs associated with THE. To compare profitability, the robotic approach was analyzed against "non-robotic" approaches of THE using F-test, Mann-Whitney U test/Student's t-test, and Fisher's exact test. Statistical significance was reported as P ≤0.05. Data are presented as median (mean ± SD).

RESULTS

67 patients underwent the robotic approach, and 15 patients underwent "non-robotic" approach; 4 were "open" and 11 were laparoscopic. 79 patients had adenocarcinoma. Operative duration for robotic THE was 327 (331 ± 82.8) vs 213 (225 ± 62.0) minutes (P = 0.0001) and estimated blood loss was 150 (184 ± 136.1) vs 300 (476 ± 708.7) mL (P = 0.0001). Length of stay was 7 (11 ± 11.8) vs 8 (12 ± 10.6) days (P = 0.76). 16 patients had post-operative complications with a Clavien-Dindo score of three or more. Hospital charges for robotic THE were $197,405 ($259,936 ± 203,630.8) vs "non-robotic" THE $159,588 ($201,565 ± $185,763.5) (P = 0.31). Cost of care for robotic THE was $34,822 ($48,844 ± $45,832.8) vs "non-robotic" THE was $23,939 ($39,386 ± $44,827.2) (P = 0.47). Payment received for robotic THE was $14,365 ($30,003 ± $40,874.7) vs "non-robotic" THE was $28,080 ($41,087 ± $44,509.1) (P = 0.41). 15% of robotic operations were profitable vs 13% of "non-robotic" operations.

CONCLUSIONS

Patients were predominantly older overweight men who had adenocarcinoma of the esophagus. The robotic approach had increased operative time and minimal blood loss. More than a fourth of operations included concomitant procedures. Patients were discharged approximately one week after THE. Overall, the robotic approach has no apparent significant differences in charges, cost, or profitability.

Robot-Assisted Esophagectomy After Neoadjuvant Chemoradiation-Current Status and Future Prospects

Multimodality treatment with neoadjuvant chemoradiation followed by surgery has become the standard of care for esophageal cancer. In the recent years, there has been a shift in focus of surgical approach from open esophagectomy to minimally invasive esophagectomy. Robot-assisted esophagectomy is being performed more often in centers across the world. However, there is limited data on role of robot-assisted esophagectomy in patients who have received neoadjuvant chemoradiation. Initial reports have shown that integrating neoadjuvant therapy to robot-assisted esophagectomy is feasible and safe. With the growing popularity of robot-assisted surgery worldwide among both surgeons and patients, understanding the impact of neoadjuvant chemoradiation on the procedure and its oncological outcome seems worthwhile. In the present study, we present a review of available literature on the feasibility and safety of robot-assisted minimally invasive esophagectomy in esophageal cancer patients after neoadjuvant chemoradiation.

Case report of simultaneous presentation of pulmonary embolism and pericardial effusion following an oncological esophagectomy

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First reported case of simultaneous pulmonary embolism and pericardial effusion following esophageal resection.

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Contradicting anticoagulation indications poses a therapeutic challenge.

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Rivaroxaban as possible cause of pericardial bleed.

Introduction

This is the first reported case of simultaneous presentation of pulmonary embolism and pericardial effusion following esophagectomy. This case illustrates a diagnostic and therapeutic challenge exemplifying the difficulties arising from complex anticoagulant considerations in esophageal cancer.

Patient case

A 72 year old male undergoes an oncological esophageal resection. Postoperatively the patient develops pulmonary embolism for which he is treated with Rivaroxaban. After starting Rivaroxaban the patient develops a large pericardial effusion.

Discussion

We suspect that the treatment of pulmonary embolism with Rivaroxaban had a causative role in the development of pericardial effusion. Based on literature we suspect that chemoradiotherapy increased susceptibility.

Conclusion

Diagnosis and treatment of simultaneous pulmonary embolism and pericardial effusion remains a challenge. Special consideration should be taken when using Rivaroxaban in esophageal cancer patients; this should always be conducted in consultation with a coagulation specialist.

Patient reported outcomes (PROs) after minimally invasive and open esophagectomy

Esophagectomy for esophageal malignancies remains an operation with significant potential morbidity and mortality. However, surgical outcomes continue to improve over time and focus has shifted toward not just good outcomes, but quality of life post operatively. Patient reported outcomes (PROs) focus of quality of life measures via validated patient surveys has increasingly become a significant focus. While PROs do have their limitations, they represent a glimpse into the symptomatology, quality of life, and well-being of a patient undergoing a procedure with inherent morbidity. Working to improve outcomes from the perspective of the patient is not a new concept, but has becoming increasingly relevant as surgical quality for all procedures improves. The optimal approach to esophagectomy is controversial. Minimally invasive approaches attempt to avoid laparotomy and thoracotomy with the thought of improving post-operative quality of life by mitigating complications related to those open surgical approaches. The data in favor of laparoscopy and thoracoscopy is quite strong and multiple randomized controlled trials exist in this realm supporting minimally invasive approaches with regards to quality of life outcomes and more rapid return to patient’s preoperative baseline. The data in favor of a robotic approach for esophagectomy is not quite as robust, but more studies show that these approaches mirror the benefits of the laparoscopic and thoracoscopic approaches without robotic assistance.

Robotic resection for esophageal cancer

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.

THE Big Deal: An Institution's Experience with Robotic Transhiatal Esophagectomy

As minimally invasive operations evolve, it is imperative to evaluate the advantages and risks involved. The aim of our study was to evaluate our institution's experience in incorporating a robotic platform for transhiatal esophagectomy (THE). Patients undergoing robotic THE were prospectively followed. Data are presented as median (mean ± SD). Forty-five patients were of 67 (67 ± 6.9) years and BMI 26 (27 ± 5.5) kg/m2. Nine per cent of operations were converted to “open,” but none in the last 25 operations. Operative duration of robotic THE was 334 (364 ± 108.8) minutes and estimated blood loss was 200 (217 ± 144.0) mL, which decreased with time ( P = 0.017). Length of stay was 8 (12 ± 11.1) days. Twenty per cent had respiratory failure requiring intubation that resolved, 4 per cent developed pneumonia, 11 per cent developed a surgical site infection, 2 per cent developed renal insufficiency, and 2 per cent developed a UTI. Two per cent (one patient) died within 30 days postoperatively, because of cardiac arrest. Our experience with robotic THE promotes robotic application because we endeavor to achieve high-level proficiency. With experience, we improved estimated blood loss and converted fewer transhiatal esophagectomies to “open.” Our length of hospital stay seems long but reflects the ill-health of patients, as does the variety of complications. Our data support the evolving future of THE, which will integrally include a robotic approach.

Minimally Invasive and Robotic Esophagectomy: A Review

Great advances have been made in the surgical management of esophageal disease since the first description of esophageal resection in 1913. We are in the era of minimally invasive esophagectomy. The current three main approaches to an esophagectomy are the Ivor Lewis technique, McKeown technique, and the transhiatal approach to esophagectomy. These operations were associated with a high morbidity and mortality. The recent advances in minimally invasive surgical techniques have greatly improved the outcomes of these surgical procedures. This article reviews the literature and describes the various techniques available for performing minimally invasive esophagectomy and robot-assisted esophagectomies, the history behind the development of these techniques, the variations, and the contemporary outcomes after such procedures.

Initial experience of robot-assisted Ivor-Lewis esophagectomy: 61 consecutive cases from a single Chinese institution

This study aims to report the technical details and preliminary outcomes of robot-assisted Ivor-Lewis esophagectomy (RAILE) using two different types of intrathoracic anastomosis from a single institution in China. From May 2015 to October 2017, 61 patients diagnosed with mid-lower esophageal cancer were treated with RAILE. The RAILE procedure was performed in two stages. The first 35 patients underwent circular end-to-end stapled intrathoracic anastomosis (stapled group), and the remaining 26 patients had a double-layered, completely hand-sewn intrathoracic anastomosis (hand-sewn group). Patient characteristics, surgical techniques, postoperative complications, and pathology outcomes were analyzed. The mean operating time and mean blood loss were 315.6 ± 59.4 minutes and 189.3 ± 95.8 mL, respectively. There was one patient who underwent conversion to thoracotomy. The 30-day and in-hospital mortality rates were 0%. Overall complications were observed in 22 patients (36.1%) according to the Clavien-Dindo (CD) and the Esophagectomy Complications Consensus Group (ECCG) classifications, of whom 6 patients (9.8%) had anastomotic leakage (ECCG, Type II). The median length of hospitalization (LOH) was 10 days (IQR, 5 days). Complete (R0) resection was achieved in all cases. The mean tumor size was 3.2 ± 1.5 cm, and the mean number of totally dissected lymph nodes was 19.3 ± 9.2. Regarding the operative outcomes between stapled and hand-sewn groups, there were no significant differences in the operative time (325.4 ± 66.6 vs. 302.3 ± 45.9 min, P = 0.114), blood loss (172.9 ± 74.1 vs. 211.5 ± 117.0 mL, P = 0.147), conversion rate (2.9 vs. 0%, P = 1.000), overall complication rate (37.1 vs. 34.6%, P = 0.839) or LOH (10 vs. 9.5 days, P = 0.415). RAILE using both stapled and hand-sewn intrathoracic anastomosis is safe and technically feasible with satisfactory perioperative outcomes for the treatment of mid-lower thoracic esophageal cancer.

Esophagectomy from then to now

We have come a long way from the onset of surgery for esophageal cancer. Surgical resection is pivotal for the long-term survival in patients with locally advanced esophageal cancer. Moreover, advancements in post-operative care and surgical techniques have contributed to reductions in morbidity. More recently minimally invasive esophagectomy has been increasingly used in patients undergoing esophageal cancer resection. Potential advantages of MIE include: the decreased pulmonary complications, lower post-operative wound infection, decreased post-operative pain, and decreased length of hospitalization. The application of robotics to esophageal surgery is becoming more widespread. Robotic esophageal surgery has potential advantages over the known limitations of laparoscopic and thoracoscopic approaches to esophagectomy while adhering to the benefits of the minimally invasive approach. This paper is a review of the evolution from open esophagectomy to the most recent robotic approach.

Operative and survival outcomes in a series of 100 consecutive cases of robot-assisted transhiatal esophagectomies

Robotic-assisted transhiatal esophagectomy (RATE) is a technically complex procedure with potential for improved postoperative outcomes. In this report, we describe our experience with RATE in a large case series. A retrospective review was conducted to collect clinical, outcomes, and survival data for 100 consecutive patients with esophageal cancer (n = 98) and benign (n = 2) conditions undergoing RATE between March 2007 and December 2014. Progression-free (PFS) and overall (OS) survival were estimated using the Kaplan-Meier curves with comparisons by log-rank tests. Median operative time and estimated blood loss were 264 minutes and 75 mL, respectively. Median intensive care unit stay was 1 day and median length of hospital stay was 8 days. Postoperative complications commonly observed were nonmalignant pleural effusion (38%) and recurrent laryngeal nerve injury (33%); 30 day mortality rate was 2%. Median number of lymph nodes removed during RATE was 17 and R0 resection was achieved in 97.8% patients. At the end of the median follow-up period of 27.7 months, median PFS was 41 months and median OS was 54 months. 1-year and 3-year PFS rates were 82% (95% CI, 75%-89%) and 53% (95% CI, 42%-62%), respectively, and OS rates were 95% (95% CI, 91%-99%) and 57% (95% CI, 46%-67%). In our experience, RATE is an effective and safe oncologic surgical procedure in a carefully selected group of patients with acceptable operative time, minimal blood loss, standard postoperative morbidity and adequate PFS and OS profiles.

Robotic-assisted Ivor Lewis esophagectomy: technique and early outcomes

Esophagectomy is pivotal for the long-term survival in patients with early stage and advanced esophageal cancer, and improved perioperative care and advanced surgical techniques have contributed to reduced postoperative morbidity. However, despite these advances, esophagectomy continues to be associated with significant morbidity and mortality. Minimally invasive esophageal surgery (MIE) has been increasingly used in patients undergoing surgery for esophageal cancer. Potential advantages of MIE include the decreased postoperative pain; lower postoperative wound infection, decreased pulmonary complications, and decreased length of hospitalization. Robotic esophageal surgery has the ability to overcome some of the limitations of laparoscopic and thoracoscopic approaches to esophagectomy while maintaining the benefits of the minimally invasive approach. In this article, we will review the clinical efficacy and outcomes associated with robotic-assisted Ivor Lewis esophagectomy (RAIL).

Robotic surgery for esophageal cancer: Merits and demerits

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

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

Simple preoperative risk scale accurately predicts perioperative mortality following esophagectomy for malignancy

Surgery remains one of the major treatment options available to patients with esophageal cancer, with high mortality in certain cohorts. The aim of this study was to develop a simple preoperative risk scale based on patient factors, hospital factors, and tumor pathology to predict the risk of perioperative mortality following esophagectomy for malignancy. The Nationwide Inpatient Sample database was used to create the risk scale. Patients who underwent open or laparoscopic transhiatal and transthoracic esophageal resection were identified using International Classification of Diseases, 9th edition codes. Patients <18 years and those with peritoneal disease were excluded. Multivariate logistic regressions were used to define a predictive model of perioperative mortality and to create a simple risk scale. From 1998 to 2011, a total of 23 751 patients underwent esophagectomy. The observed overall perioperative mortality rate for this cohort was 7.7%. Minimally invasive techniques, and operations performed in higher volume centers were protective, whereas increasing age, comorbidities and diagnosis of squamous cell carcinoma were independent predictors of mortality. Based on this population, a risk scale from 0-16 was created. The calibration revealed a good agreement between the observed and risk scale-predicted probabilities. A set of sensitivity/specificity analyses was then performed to define normal (score 0-7) and high risk (score 8-16) patients for clinical practice. Mortality in patients with a score of 0-7 ranged from 1.3-7.6%, compared with 10.5-34.5% in patients with a score of 8-16. This simple preoperative risk scale may accurately predict the risk of perioperative mortality following esophagectomy for malignancy and can be used as a clinical tool for preoperative counseling.

Robotic surgery for upper gastrointestinal cancer: Current status and future perspectives

Robotic surgery with the da Vinci Surgical System has been increasingly applied in a wide range of surgical specialties, especially in urology and gynecology. However, in the field of upper gastrointestinal (GI) tract, the da Vinci Surgical System has yet to be standard as a result of a lack of clear benefits in comparison with conventional minimally invasive surgery. We have been carrying out robotic gastrectomy and esophagectomy for operable patients with resectable upper GI malignancies since 2009, and have demonstrated the potential advantages of the use of the robot in possibly reducing postoperative local complications including pancreatic fistula following gastrectomy and recurrent laryngeal nerve palsy after esophagectomy, even though there have been a couple of problems to be solved including longer duration of operation and higher cost. The present review provides updates on robotic surgery for gastric and esophageal cancer based on our experience and review of the literature.

Mortality after esophagectomy is heavily impacted by center volume: retrospective analysis of the Nationwide Inpatient Sample

BACKGROUND

The effects of hospital volume on in-hospital mortality after esophageal resection are disputed in the literature. We sought to analyze treatment effects in patient subpopulations that undergo esophagectomy for cancer based on hospital volume.

METHODS

We performed a retrospective analysis of the Nationwide Inpatient Sample from 1998 to 2011. Patients who underwent open or laparoscopic transhiatal and transthoracic esophageal resection were identified using ICD-9 codes. Patients <18 years and those with peritoneal disease were excluded. Multivariate logistic regression analyses were used with mortality as the independent variable to evaluate the effect of low (<6), intermediate (6-19), and high (≥20) hospital volume of esophagectomies. These analyses were repeated in different subsets of patients to determine whether hospital volume affected mortality depending on the subpopulation evaluated. Subgroups were created depending on age, race, gender, operative approach, comorbidities, and tumor pathology.

RESULTS

A total of 23,751 patients were included. The overall perioperative mortality rate was 7.7 % (low volume: 11.4 %; intermediate volume: 8.39 %, high volume: 4.01 %), and multivariate analysis revealed that high hospital volume had a protective effect (OR 0.54, 95 % CI 0.45-0.65). On subgroup analyses for low- and intermediate-volume hospitals, mortality was uniformly elevated for the subpopulations when comparing to high-volume hospitals (p < 0.05). There was no difference in mortality between low- and medium-volume hospitals and between subgroups.

CONCLUSION

No lower mortality risk subgroup could be identified in this nationwide collective. This analysis emphasizes that perioperative mortality after esophagectomy for cancer is lower in high-volume hospitals.

The surgical management of esophago-gastric junctional cancer

The best available surgical strategy in the treatment of resectable esophago-gastric junctional (EGJ) cancer is a controversial topic. In this review we evaluate the current literature and scientific evidence examining the surgical treatment of locally advanced EGJ cancer by comparing esophagectomy with gastrectomy, transhiatal with transthoracic esophagectomy, minimally invasive with open esophagectomy, and less extensive with more extensive lymphadenectomy. We also assess endoscopic procedures increasingly used for early EGJ cancer. The current evidence does not favor any of the techniques over the others in terms of oncological outcomes. Health-related quality of life may be better following gastrectomy compared to esophagectomy. Minimally invasive procedures might be less prone to surgical complications. Endoscopic techniques are safe and effective alternatives for early-stage EGJ cancer in the short term, but surgical treatment is the mainstay in fit patients due to the risk of lymph node metastasis. Any benefit of lymphadenectomy extending beyond local or regional nodes is uncertain. This review demonstrates the great need for well-designed clinical studies to improve the knowledge in how to optimize and standardize the surgical treatment of EGJ cancer.

The benefits and limitations of robotic assisted transhiatal esophagectomy for esophageal cancer

Robotic-assisted transhiatal esophagectomy (RATE) is a minimally invasive approach to total esophagectomy with less morbidity but equivalent efficacy when compared with the traditional open approach. The robotic platform offers numerous technical advantages that assist with the esophageal dissection, which allows the procedure to be completed without entry into the thoracic cavity. The major criticism of the transhiatal approach is that it forfeits the ability of the surgeon to perform a formal lymphadenectomy, but this does not appear to affect long-term survival.

Robot-Assisted Mckeown Esophagectomy is Feasible After Neoadjuvant Chemoradiation. Our Initial Experience

Neoadjuvant chemoradiation has become the standard of care for esophageal cancer, especially for middle third esophageal lesions and those with squamous histology. Although more and more thoracic surgeons and surgical oncologists have now shifted to video-assisted and robot-assisted thoracoscopic esophagectomy; there is still limited experience for the use of minimal-assisted approaches in patients undergoing surgery after neoadjuvant chemoradiation. Most surgeons have concerns of feasibility, safety, and oncological outcomes as well as issues related to difficult learning curve in adopting robotic esophagectomy in patients after chemoradiation. We present our initial experience of Robot-Assisted Mckeown Esophagectomy in 27 patients after neoadjuvant chemoradiation, from May 2013 to October 2014. All patients underwent neoadjuvant chemoradiation to a dose of 50.4 Gy/25Fr with concurrent weekly cisplatin, followed by reassessment with clinical examination and repeat FDG PET/CT 6 weeks after completion of chemoradiation. Patients with progressive disease underwent palliative chemotherapy while patients with either partial or significant response to chemoradiation underwent Robot-Assisted Mckeown Esophagectomy with esophageal replacement by gastric conduit and esophagogastric anastomosis in the left neck. Out of 27 patients, 92.5 % patients had stage cT3/T4 tumours and node-positive disease in 48.1 % on imaging. Most patients were middle thoracic esophageal cancers (23/27), with squamous histology in all except for one. All patients received neoadjuvant chemoradiation and subsequently underwent Robot Assisted Mckeown Esophagectomy. The average time for robot docking, thoracic mobilization and total surgical procedure was 13.2, 108.4 and 342.7 min, respectively. The procedure was well tolerated by all patients with only one case of peri-operative mortality. Average ICU stay was 6.35 days (range 3-9 days). R0 resection rate of 96.3 % and average lymph node yield of 18 could be achieved. Pathological node negativity rate (pN0) and complete response (pCR) were 66.6 and 44.4 %, respectively. In the initial cases, four patients had to be converted to open due technical reasons or intraoperative complications. The present study, with shorter operative times, similar ICU stay, overall low morbidity, and mortality and optimal oncological outcomes suggest that robot-assisted thoracic mobilization of esophagus in patients with prior chemoradiation is feasible and safe with acceptable oncological outcomes. It has a shorter learning curve and hence allows for a transthoracic minimally invasive transthoracic esophagectomy to more and more patients, otherwise unfit for conventional approach.

Minimally invasive surgery for upper gastrointestinal cancer: Our experience and review of the literature

Minimally invasive surgery (MIS) for upper gastrointestinal (GI) cancer, characterized by minimal access, has been increasingly performed worldwide. It not only results in better cosmetic outcomes, but also reduces intraoperative blood loss and postoperative pain, leading to faster recovery; however, endoscopically enhanced anatomy and improved hemostasis via positive intracorporeal pressure generated by CO2 insufflation have not contributed to reduction in early postoperative complications or improvement in long-term outcomes. Since 1995, we have been actively using MIS for operable patients with resectable upper GI cancer and have developed stable and robust methodology in conducting totally laparoscopic gastrectomy for advanced gastric cancer and prone thoracoscopic esophagectomy for esophageal cancer using novel technology including da Vinci Surgical System (DVSS). We have recently demonstrated that use of DVSS might reduce postoperative local complications including pancreatic fistula after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. In this article, we present the current status and future perspectives on MIS for gastric and esophageal cancer based on our experience and a review of the literature.

Intraoperative Endoscopic Botox Injection During Total Esophagectomy Prevents the Need for Pyloromyotomy or Dilatation

BACKGROUND

Esophagectomy may lead to impairment in gastric emptying unless pyloric drainage is performed. Pyloric drainage may be technically challenging during minimally invasive esophagectomy and can add morbidity. We sought to determine the effectiveness of intraoperative endoscopic injection of botulinum toxin into the pylorus during robotic-assisted esophagectomy as an alternative to surgical pyloric drainage.

MATERIALS AND METHODS

We performed a retrospective analysis of patients with adenocarcinoma and squamous cell carcinoma of the distal esophagus or gastroesophageal junction who underwent robotic-assisted transhiatal esophagectomy (RATE) without any surgical pyloric drainage. Patients with and without intraoperative endoscopic injection of 200 units of botulinum toxin in 10 cc of saline (BOTOX group) were compared to those that did not receive any pyloric drainage (noBOTOX group). Main outcome measure was the incidence of postoperative pyloric stenosis; secondary outcomes included operative and oncologic parameters, length of stay (LOS), morbidity, and mortality.

RESULTS

From November 2006 to August 2014, 41 patients (6 females) with a mean age of 65 years underwent RATE without surgical drainage of the pylorus. There were 14 patients in the BOTOX group and 27 patients in the noBOTOX group. Mean operative time was not different between the comparison groups. There was one conversion to open surgery in the BOTOX group. No pyloric dysfunction occurred in the BOTOX group postoperatively, and eight stenoses in the noBOTOX group (30%) required endoscopic therapy (P < .05). There were no differences in incidence of anastomotic strictures or anastomotic leaks. One patient in group noBOTOX required pyloroplasty 3 months after esophagectomy. There was one death in the noBOTOX group postoperatively (30-day mortality 2.4%). Mean LOS was 9.6 days, and BOTOX patients were discharged earlier (7.4 versus 10.7, P < .05).

CONCLUSION

Intraoperative endoscopic injection of botulinum toxin into the pylorus during RATE is feasible, safe, and effective and can prevent the need for pyloromyotomy.

Robot-assisted minimally invasive esophagectomy for esophageal cancer: A systematic review

This paper describes the technique of robot-assisted minimally invasive esophagectomy. (RAMIE) Also, a systematic literature search was performed. Safety and feasibility of RAMIE was demonstrated in all reports. Short term oncologic results show radical resection rates of 77-100% and 18-43 lymph nodes harvested. RAMIE offers great visualization of the mediastinum and enables meticulous dissection in the mediastinum from diaphragm to thoracic inlet.

Robotic oncologic complexity score - a new tool for predicting complications in computer-enhanced oncologic surgery

BACKGROUND

While there is little doubt that robotic interventions have already opened new horizons in surgery due to its inherent complexity, there is still an unmet need for tools allowing center-to-center performance comparisons. A complexity score could be a valuable instrument for further research.

METHODS

The items of the robotic oncologic complexity score (ROCS) were based on risk factors identified in previous studies. We attempt to build the score and validate it on 400 consecutive cases of robotic oncologic surgery. The primary endpoint is to assess the value of ROCS in predicting major complications.

RESULTS

The mean ROCS in the group was 3.3(+/-1.4). Different correlations were calculated: the score and the complications (r=0.38), the major complications (r=0.42), Clavien grade (r=0.5), the operating time (r=0.35), and the length of stay (r=0.47). On the ROC-curve a score >4 has the best specificity and sensibility for predicting major complications (P<0.05).

CONCLUSION

ROCS has potential in predicting complications and hospital length of stay, as well as a role in classifying oncologic robotic surgical interventions. Copyright © 2015 John Wiley & Sons, Ltd.