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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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Minamimura K, Aoki Y, Kaneya Y, Matsumoto S, Arai H, Kakinuma D, Oshiro Y, Kawano Y, Watanabe M, Nakamura Y, Suzuki H, Yoshida H. Current Status of Robotic Hepatobiliary and Pancreatic Surgery. J NIPPON MED SCH 2024; 91:10-19. [PMID: 38233127 DOI: 10.1272/jnms.jnms.2024_91-109] [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] [Indexed: 01/19/2024]
Abstract
Laparoscopic surgery is performed worldwide and has clear economic and social benefits in terms of patient recovery time. It is used for most gastrointestinal surgical procedures, but laparoscopic surgery for more complex procedures in the esophageal, hepatobiliary, and pancreatic regions remains challenging. Minimally invasive surgery that results in accurate tumor dissection is vital in surgical oncology, and development of surgical systems and instruments plays a key role in assisting surgeons to achieve this. A notable advance in the latter half of the 1990s was the da Vinci Surgical System, which involves master-slave surgical support robots. Featuring high-resolution three-dimensional (3D) imaging with magnification capabilities and forceps with multi-joint function, anti-shake function, and motion scaling, the system compensates for the drawbacks of conventional laparoscopic surgery. It is expected to be particularly useful in the field of hepato-biliary-pancreatic surgery, which requires delicate reconstruction involving complex liver anatomy with diverse vascular and biliary systems and anastomosis of the biliary tract, pancreas, and intestines. The learning curve is said to be short, and it is hoped that robotic surgery will be standardized in the near future. There is also a need for a standardized robotic surgery training system for young surgeons that can later be adapted to a wider range of surgeries. This systematic review describes trends and future prospects for robotic surgery in the hepatobiliary-pancreatic region.
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Affiliation(s)
| | - Yuto Aoki
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Youhei Kaneya
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | | | - Hiroki Arai
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Daisuke Kakinuma
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Yukio Oshiro
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Yoichi Kawano
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | | | | | - Hideyuki Suzuki
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
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Bao T, Chen P, Yu J, Cai DH, He XD, Wang YJ, Xie XF, Li KK, Zhao XY, Guo W. Learning curve in relation to health-related quality of life in long-term, disease free survivors after McKeown minimally invasive esophagectomy. Surg Endosc 2024; 38:671-678. [PMID: 38012442 DOI: 10.1007/s00464-023-10553-5] [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: 08/24/2023] [Accepted: 10/20/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND The potential impact of learning curve on long-term health-related quality of life (QoL) after esophagectomy for cancer has not been investigated. The aim of this article is to investigate the relationship between learning curve for McKeown minimally invasive esophagectomy (MIE) and health-related quality of life (QoL) in long-term, disease free survivors up to 10 years after esophageal cancer resection. METHODS Esophageal cancer patients who underwent McKeown MIE between 2009 and 2019 were identified in which 280 who were free of disease at the time of survey and completed health-related QoL and symptom questionnaires, including EORTC QLQ-C30, EORTC QLQ-OES18, and Digestive Symptom Questionnaire. Patients were assessed in 3 cohorts according to the learning phases of expertise reported by our previous study: initial phase; plateau phase, and; experienced phase. RESULTS Median time from operation to survey was 5.8 years (interquartile range 4.6-8.2). The QLQ-C30 mean scores of functional scales, and symptom scales of respiratory and digestive systems including dyspnea (P = 0.006), shortness of breath (P = 0.003), and dysphagia (P = 0.031) were significantly better in experienced phase group. Furthermore, in the subgroup analyses for patients without postoperative major complications, patients in the initial learning phase remained suffering from more symptoms of dyspnea (P = 0.040) and shortness of breath (P = 0.001). CONCLUSION Esophageal cancer patients undergoing McKeown MIE in initial learning phase tend to suffer from a deterioration in long-term health-related QoL and higher symptomatic burden as compared to experienced learning phase, which did not improved over time and warranted more attention.
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Affiliation(s)
- Tao Bao
- Army Medical University, Gaotanyan Route 30#, Chongqing, 400038, People's Republic of China
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Ping Chen
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Jun Yu
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Dao-Hong Cai
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Xian-Dong He
- Army Medical University, Gaotanyan Route 30#, Chongqing, 400038, People's Republic of China
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Ying-Jian Wang
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Xian-Feng Xie
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Kun-Kun Li
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Xiao-Ying Zhao
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Wei Guo
- Army Medical University, Gaotanyan Route 30#, Chongqing, 400038, People's Republic of China.
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, People's Republic of China.
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Fang Y, Wang Z, Yang YQ, Song BW, Gou WB. Multiple heterotopic sebaceous glands in the oesophagus: A case report and literature review. Trop Doct 2024; 54:49-52. [PMID: 37876288 DOI: 10.1177/00494755231206416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Affiliation(s)
- Yuan Fang
- Assistant Researcher, Department of Clinical Research Management, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Zhi Wang
- Research Assistant, Department of Clinical Research Management, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yong Qiang Yang
- Associate chief physician and Head, Department of Endoscopy, People's Hospital of Wanning, Wanning, Hainan, China
| | - Bei Wen Song
- Supervisor nurse,Department of Endoscopy, People's Hospital of Wanning, Wanning, Hainan, China
| | - Wen Bin Gou
- Associate chief physician and Head, Department of Pathology, People's Hospital of Wanning, Wanning, Hainan, China
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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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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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7
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Narendra A, Barbour A. Introducing robotic oesophagectomy into an Australian practice: an assessment of the early procedural outcomes and learning curve. ANZ J Surg 2023; 93:1300-1305. [PMID: 37043677 DOI: 10.1111/ans.18445] [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: 12/18/2022] [Revised: 03/07/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Robotic oesophagectomy (RAMIO) is a novel procedure in Australia and New Zealand. We aimed to report the early operative and clinical outcomes achieved during the introduction of RAMIO into the practice of a single Australian surgeon and benchmark these against outcomes of patients receiving conventional minimally invasive oesophagectomy (MIO) by the same surgeon. METHODS Data on all patients undergoing RAMIO, performed by a single high-volume Australian surgeon, were collected from a prospectively maintained database. Operative, clinical and surgical quality outcomes were benchmarked on a univariable basis against those of patients receiving MIO. Learning curves were computed using quadratic and linear regression of operating times on case-numbers and compared using Cox regression modelling. RESULTS 290 patients (237 MIO, 53 RAMIO (47% Ivor-Lewis, 53% McKeon oesophagectomy)) were included. Compared with MIO, the median thoracic operating time was 20 min longer for RAMIO (P = 0.03). Following RAMIO, there was less blood loss (P < 0.01) and a shorter length of stay (P < 0.01).There were no differences in morbidity and quality of surgery following RAMIO compared with MIO. There were no deaths following RAMIO. Having progressed from MIO, the operating times for RAMIO improved after 22 cases compared with MIO (110 cases) (HR 0.70 (0.51-0.93), P = 0.01). CONCLUSION With careful implementation, RAMIO may be safely performed within the Australian setting and is associated with a modest increase in procedure duration, but less blood loss and shorter length of stay compared with conventional MIO.
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Affiliation(s)
- Aaditya Narendra
- The Princess Alexandra Hospital, University of Queensland, Brisbane, Queensland, Australia
| | - Andrew Barbour
- The Princess Alexandra Hospital, University of Queensland, Brisbane, Queensland, Australia
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Duan X, Yue J, Shang X, Chen C, Ma Z, Chen Z, Zhang C, Jiang H. Learning Curve of Robot-Assisted Lymph Node Dissection of the Left Recurrent Laryngeal Nerve: A Retrospective Study of 417 Patients. Ann Surg Oncol 2023:10.1245/s10434-023-13430-6. [PMID: 37029262 DOI: 10.1245/s10434-023-13430-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/12/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE Left recurrent laryngeal nerve (no.106recL) lymph node dissection is a challenging procedure, and robotic-assisted minimally invasive esophagectomy (RAMIE) may have some advantages. This study aimed to determine the learning curve of no.106recL lymph node dissection. METHODS The data of 417 patients who underwent McKeown RAMIE between June 2017 and June 2022 were retrospectively analyzed. The lymph node harvest of no.106recL was used to determine the learning curve, and the cumulative sum (CUSUM) method was employed to obtain the inflection point. RESULTS A total of 404 patients (404/417, 96.9%) underwent robotic surgery. Based on the number of no.106recL lymph nodes harvested, the CUSUM learning curve was mapped and divided into three phases: phase I (1‒75 cases), phase II (76‒240 cases), and phase III (241‒404 cases). The median (IQR) number of no.106recL lymph node harvests were 1 (4), 3 (6,) and 4 (4) in each phase (p < 0.001). The lymph node dissection rate gradually increased from 62.7% in phase I to 82.9% in phase III (p = 0.001). The total and thoracic lymph node harvest gradually increased (p < 0.001), whereas operation time (p = 0.001) and blood loss gradually decreased (p < 0.001). Moreover, the incidence of total complication (p = 0.020) and recurrent laryngeal nerve injury (p = 0.001) significantly decreased, and the postoperative hospital stay gradually shortened (p < 0.001). CONCLUSION Robotic no.106recL lymph node dissection has some advantages for patients with esophageal cancer. In this study, perioperative and clinical outcomes were significantly improved over the learning curve. However, further prospective studies are required to confirm our results.
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Affiliation(s)
- Xiaofeng Duan
- Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin, China.
| | - Jie Yue
- Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin, China
| | - Xiaobin Shang
- Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin, China
| | - Chuangui Chen
- Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin, China
| | - Zhao Ma
- Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin, China
| | - Zuoyu Chen
- Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin, China
| | - Chen Zhang
- Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin, China
| | - Hongjing Jiang
- Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin, China.
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Weindelmayer J, De Pasqual CA, Turolo C, Gervasi MC, Sacco M, Bencivenga M, Giacopuzzi S. Robotic versus open Ivor–Lewis esophagectomy: A more accurate lymph node dissection without burdening the leak rate. J Surg Oncol 2023; 127:1109-1115. [PMID: 36971002 DOI: 10.1002/jso.27246] [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: 12/08/2022] [Revised: 01/24/2023] [Accepted: 03/02/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Robotic-assisted minimally invasive esophagectomy (RAMIE) combines the beneficial effects of minimally invasive surgery on postoperative complications, especially on pulmonary ones, with the safety of the anastomosis performed in open surgery. Moreover, RAMIE could allow a more accurate lymphadenectomy. METHODS We reviewed our database to identify all patients with adenocarcinoma of the esophagus treated by Ivor-Lewis esophagectomy in the period January 2014 to June 2022. Patients were divided according to the thoracic approach into RAMIE and open esophagectomy (OE) groups. We compared the groups for early surgical outcomes, 90-day mortality as well as R0 rate, and the number of lymph nodes harvested. RESULTS We identified 47 patients in RAMIE and 159 patients in the OE group. Baseline characteristics were comparable. Operative time was significantly longer for RAMIE procedures (p < 0.01); however, we did not observe the difference in overall (RAMIE 55.5% vs. OE 61%, p = 0.76) and severe complications rate (RAMIE 17% vs. OE 22.6%, p = 0.4). The anastomotic leak rate was 2.1% after RAMIE and 6.9% after OE (p = 0.56). We did not report the difference in 90-day mortality (RAMIE 2.1% vs. OE 1.9%, p = 0.65). In the RAMIE group, we observed a significantly higher number of thoracic lymph nodes harvested, with a median of 10 lymph nodes in the RAMIE group versus 8 in the OE group (p < 0.01). CONCLUSIONS In our experience, RAMIE has morbimortality rates comparable to OE. Moreover, it allows a more accurate thoracic lymphadenectomy which results in a higher thoracic lymph nodes retrieval rate.
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Affiliation(s)
- Jacopo Weindelmayer
- Department of General and Upper G.I. Surgery, University of Verona, Verona, Italy
| | | | - Cecilia Turolo
- Department of General and Upper G.I. Surgery, University of Verona, Verona, Italy
| | - Maria Clelia Gervasi
- Department of General and Upper G.I. Surgery, University of Verona, Verona, Italy
| | - Michele Sacco
- Department of General and Upper G.I. Surgery, University of Verona, Verona, Italy
| | - Maria Bencivenga
- Department of General and Upper G.I. Surgery, University of Verona, Verona, Italy
| | - Simone Giacopuzzi
- Department of General and Upper G.I. Surgery, University of Verona, Verona, Italy
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Sun HB, Liu XB, Xing WQ, Chen PN, Liu SL, Li P, Ma YX, Feng SK, Jiang D, Yan S. Initial experience with modified en bloc robot-assisted minimally invasive oesophagectomy for thoracic oesophageal squamous cell carcinoma. Int J Med Robot 2023; 19:e2506. [PMID: 36786383 DOI: 10.1002/rcs.2506] [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: 11/03/2022] [Revised: 01/06/2023] [Accepted: 02/06/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND The feasibility and safety of en bloc robot-assisted minimally invasive oesophagectomy (RAMIE) need to be verified. METHODS Forty-seven patients who received conventional RAMIE and 31 who received modified en bloc RAMIE at Henan Cancer Hospital were included in the study cohort. We compared the perioperative outcomes of conventional RAMIE and modified en bloc RAMIE. RESULTS Compared with the conventional RAMIE group, the en bloc RAMIE group yielded a higher total number of lymph nodes (p = 0.001), especially thoracic lymph nodes (p = 0.025) and left recurrent laryngeal nerve (RLN) lymph nodes (p = 0.005). No notable differences were found in the rate of total complications (p = 0.663) or RLN injury (p = 0.891) between the two groups. The preoperative and postoperative serological indicators were comparable between the two groups. CONCLUSIONS Modified en bloc RAMIE was safe and feasible for patients with oesophageal squamous cell carcinoma and improved lymph node dissection, especially thoracic and left RLN lymph node dissection.
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Affiliation(s)
- Hai-Bo Sun
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Xian-Ben Liu
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Wen-Qun Xing
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Pei-Nan Chen
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Shi-Lei Liu
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Peng Li
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Ya-Xing Ma
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Shao-Kang Feng
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Duo Jiang
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Sen Yan
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
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11
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Minamimura K, Hara K, Matsumoto S, Yasuda T, Arai H, Kakinuma D, Ohshiro Y, Kawano Y, Watanabe M, Suzuki H, Yoshida H. Current Status of Robotic Gastrointestinal Surgery. J NIPPON MED SCH 2023; 90:308-315. [PMID: 37690822 DOI: 10.1272/jnms.jnms.2023_90-404] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Development of surgical support robots began in the 1980s as a navigation and auxiliary device for endoscopic surgery. For remote surgery on the battlefield, a master-slave-type surgical support robot was developed, in which a console surgeon operates the robot at will. The da Vinci surgical system, which currently dominates the global robotic surgery market, received United States Food and Drug Administration and regulatory approval in Japan in 2000 and 2009 respectively. The latest, fourth generation, da Vinci Xi has a good field of view via a three-dimensional monitor, highly operable forceps, a motion scale function, and a tremor-filtered articulated function. Gastroenterological tract robotic surgery is safe and minimally invasive when accessing and operating on the esophagus, stomach, colon, and rectum. The learning curve is said to be short, and robotic surgery will likely be standardized soon. Therefore, robotic surgery training should be systematized for young surgeons so that it can be further standardized and later adapted to a wider range of surgeries. This article reviews current trends and potential developments in robotic surgery.
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Affiliation(s)
| | - Keisuke Hara
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | | | - Tomohiko Yasuda
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Hiroki Arai
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Daisuke Kakinuma
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Yukio Ohshiro
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Youichi Kawano
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | | | - Hideyuki Suzuki
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
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12
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Takeuchi M, Kawakubo H, Saito K, Maeda Y, Matsuda S, Fukuda K, Nakamura R, Kitagawa Y. Automated Surgical-Phase Recognition for Robot-Assisted Minimally Invasive Esophagectomy Using Artificial Intelligence. Ann Surg Oncol 2022; 29:6847-6855. [PMID: 35763234 DOI: 10.1245/s10434-022-11996-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/11/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although a number of robot-assisted minimally invasive esophagectomy (RAMIE) procedures have been performed due to three-dimensional field of view, image stabilization, and flexible joint function, both the surgeons and surgical teams require proficiency. This study aimed to establish an artificial intelligence (AI)-based automated surgical-phase recognition system for RAMIE by analyzing robotic surgical videos. METHODS This study enrolled 31 patients who underwent RAMIE. The videos were annotated into the following nine surgical phases: preparation, lower mediastinal dissection, upper mediastinal dissection, azygos vein division, subcarinal lymph node dissection (LND), right recurrent laryngeal nerve (RLN) LND, left RLN LND, esophageal transection, and post-dissection to completion of surgery to train the AI for automated phase recognition. An additional phase ("no step") was used to indicate video sequences upon removal of the camera from the thoracic cavity. All the patients were divided into two groups, namely, early period (20 patients) and late period (11 patients), after which the relationship between the surgical-phase duration and the surgical periods was assessed. RESULTS Fourfold cross validation was applied to evaluate the performance of the current model. The AI had an accuracy of 84%. The preparation (p = 0.012), post-dissection to completion of surgery (p = 0.003), and "no step" (p < 0.001) phases predicted by the AI were significantly shorter in the late period than in the early period. CONCLUSIONS A highly accurate automated surgical-phase recognition system for RAMIE was established using deep learning. Specific phase durations were significantly associated with the surgical period at the authors' institution.
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Affiliation(s)
- Masashi Takeuchi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
| | - Kosuke Saito
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yusuke Maeda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazumasa Fukuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Rieko Nakamura
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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13
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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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14
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Zhang CD, Takeshima H, Sekine S, Yamashita S, Liu YY, Hattori N, Abe H, Yamashita H, Fukuda M, Imamura Y, Ushiku T, Katai H, Makino H, Watanabe M, Seto Y, Ushijima T. Prediction of tissue origin of adenocarcinomas in the esophagogastric junction by DNA methylation. Gastric Cancer 2022; 25:336-345. [PMID: 34557982 DOI: 10.1007/s10120-021-01252-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 09/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prediction of tissue origin of esophagogastric junction (EGJ) adenocarcinomas can be important for therapeutic decision, but no molecular marker is available. Here, we aimed to develop such a marker taking advantage of tissue-specific profiles of DNA methylation. METHODS DNA methylation profiles of gastric adenocarcinomas (GACs) were obtained by an Infinium HumanMethylation450 BeadChip array, and those of esophageal adenocarcinoma (EACs) were obtained from the TCGA database. DNA from formalin-fixed paraffin-embedded (FFPE) samples was analyzed by bisulfite pyrosequencing. RESULTS In the screening set, 51 of 145,841 CpG sites in CpG islands were methylated at significantly higher levels in 30 GACs compared to those in 30 EACs. Among them, SLC46A3 and cg09177106 were unmethylated in all the 30 EACs. Predictive powers of these two markers were successfully confirmed in an independent validation set (18 GACs and 18 EACs) (SLC46A3, sensitivity = 77.8%, specificity = 100%; cg09177106, sensitivity = 83.3%, specificity = 94.4%), and could be applied to FFPE samples (37 GACs and 18 EACs) (SLC46A3, P = 0.0001; cg09177106, P = 0.0028). On the other hand, EAC-specific markers informative in the FFPE samples could not be isolated. Using these GAC-specific markers, nine of 46 (19.6%) TCGA EGJ adenocarcinomas were predicted to be GACs. CONCLUSIONS Two GAC-specific markers, SLC46A3 and cg09177106, had a high specificity for identifying the tissue origin of EGJ adenocarcinoma.
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Affiliation(s)
- Chun-Dong Zhang
- Division of Epigenomics, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.,Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan
| | - Hideyuki Takeshima
- Division of Epigenomics, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Shigeki Sekine
- Division of Pathology and Clinical Laboratories, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Satoshi Yamashita
- Division of Epigenomics, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Yu-Yu Liu
- Division of Epigenomics, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Naoko Hattori
- Division of Epigenomics, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Hiroyuki Abe
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan
| | - Hiroharu Yamashita
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan
| | - Masahide Fukuda
- Division of Epigenomics, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, 135-8550, Japan
| | - Tetsuo Ushiku
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan
| | - Hitoshi Katai
- Department of Gastric Surgery, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Hiroshi Makino
- Department of Surgery, Tama-Nagayama Hospital, Nippon Medical School, Tokyo, 206-8512, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, 135-8550, Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan
| | - Toshikazu Ushijima
- Division of Epigenomics, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
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Kanamori J, Watanabe M, Maruyama S, Kanie Y, Fujiwara D, Sakamoto K, Okamura A, Imamura Y. Current status of robot-assisted minimally invasive esophagectomy: what is the real benefit? Surg Today 2021; 52:1246-1253. [PMID: 34853881 DOI: 10.1007/s00595-021-02432-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/26/2021] [Indexed: 12/15/2022]
Abstract
Robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer has been performed increasingly frequently over the last few years. Robotic systems with articulated devices and tremor filtration allow surgeons to perform such procedures more meticulously than by hand. The feasibility of RAMIE has been demonstrated in several retrospective comparative studies, which showed similar short-term outcomes to conventional minimally invasive esophagectomy (cMIE). Considering the number of harvested lymph nodes, RAMIE may be superior to cMIE in terms of left upper mediastinal lymph node dissection. However, whether or not the addition of a robotic system to cMIE can help improve perioperative and oncological outcomes remains unclear. Given the lack of established evidence from randomized controlled trials, we must await the results of ongoing studies to reach any meaningful conclusions. Further advancements in robotic platforms, as well as the reduction in medical expenses, will be essential to demonstrate the real benefit of RAMIE.
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Affiliation(s)
- Jun Kanamori
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Masayuki Watanabe
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Suguru Maruyama
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yasukazu Kanie
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Daisuke Fujiwara
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Kei Sakamoto
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akihiko Okamura
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Imamura
- Department of Esophageal Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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16
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Prasad P, Wallace L, Navidi M, Phillips AW. Learning curves in minimally invasive esophagectomy: A systematic review and evaluation of benchmarking parameters. Surgery 2021; 171:1247-1256. [PMID: 34852934 DOI: 10.1016/j.surg.2021.10.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/20/2021] [Accepted: 10/21/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Minimally invasive techniques are increasingly used in the treatment of esophageal cancer. The learning curve for minimally invasive esophagectomy is variable and can impact patient outcomes. The aim of this study was to review the current evidence on learning curves in minimally invasive esophagectomy and identify which parameters are used for benchmarking. METHODS A search of the major reference databases (PubMed, Medline, Cochrane) was performed with no time limits up to February 2020. Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if an assessment of the learning curve was reported on, regardless of which (if any) statistical method was used. RESULTS Twenty-nine studies comprising 3,741 patients were included. Twenty-two studies reported on a combination of thoracoscopic, hybrid, and total minimally invasive esophagectomy, 6 studies reported robotic-assisted minimally invasive esophagectomy alone, and 1 study evaluated both robotic-assisted minimally invasive esophagectomy and thoracoscopic esophagectomies. Operating time was the most frequently used parameter to determine learning curve progression (23/39 studies), with number of resected lymph nodes, morbidity, and blood loss also frequently used. Learning curves were found to plateau at 7 to 60 cases for thoracoscopic esophagectomy, 12 to 175 cases for total and thoracoscopic/hybrid esophagectomy, and 9 to 85 cases for robotic-assisted minimally invasive esophagectomy. CONCLUSION Multiple parameters are employed to gauge minimally invasive esophagectomy learning curve progression. However, there are no validated or approved sets of outcomes. Further work is required to determine the optimum parameters that should be used to ensure best patient outcomes and required length of proctoring.
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Affiliation(s)
- Pooja Prasad
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK.
| | - Lauren Wallace
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Maziar Navidi
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK. https://www.twitter.com/Maz_Surgery
| | - Alexander W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK; School of Medical Education, Newcastle University, Newcastle Upon Tyne, UK. https://www.twitter.com/AlexWPhillips7
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17
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Park BJ, Kim DJ. Robot-Assisted Thoracoscopic Esophagectomy with Total Mediastinal Lymphadenectomy: A Guide to a Systematic Approach Using the Concept of Fascial Plane Dissection. J Chest Surg 2021; 54:294-301. [PMID: 34353970 PMCID: PMC8350464 DOI: 10.5090/jcs.21.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/02/2021] [Indexed: 12/02/2022] Open
Abstract
Recent case series and meta-analyses have suggested that robot-assisted minimally invasive esophagectomy (RAMIE) could be a useful alternative to video-assisted thoracic surgery esophagectomy. The advantages of RAMIE are a 3-dimensional view, 7 degrees of freedom, and tremor filtering, which enable more meticulous lymph node dissection with a lower incidence of complications. However, in radical esophagectomy, understanding the concepts of the fascia and compartment is crucial for successful and reliable dissection. The first RAMIE in Korea was performed by our team in July 2006, and since then, we have developed related techniques to achieve better short- and long-term outcomes. The key step in RAMIE for esophageal squamous cell carcinoma is dissection of the upper mediastinum due to the difficulty of lymph node dissection and the high incidence of nodal metastasis in the area. Herein, we describe the technique of fascial plane dissection with esophageal suspension during RAMIE.
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Affiliation(s)
- Byung Jo Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Joon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
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18
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Sayed AI, Goel S, Aggarwal A, Singh S. Robot assisted minimally invasive esophagectomy: safety, perioperative morbidity and short-term oncological outcome-a single institution experience. J Robot Surg 2021; 16:517-525. [PMID: 34228249 DOI: 10.1007/s11701-021-01274-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 06/26/2021] [Indexed: 11/30/2022]
Abstract
Robot assisted minimally invasive esophagectomy (RAMIE) has evolved over the past decade to become procedure of choice at many centers all over the world. The objective of this study is to present our experience of robot assisted minimally invasive esophagectomy with respect to perioperative morbidity and short-term oncological outcomes and a comparison of the same to a cohort of our patients who underwent open Mckeown's esophagectomy. This is a retrospective analysis of prospectively collected data of patients from October 2011 to October 2019. A total of 56 patients in open group and 58 patients in robotic group were enrolled. Upper and middle third was the most common site for open esophagectomy while middle and lower third was more common site for robotic esophagectomy (p < 0.0001). Median operative time was 340 min for open and 360 min for robotic esophagectomy (p = 0.004). A median of 16 lymph nodes were retrieved in either group. R0 resection was achieved in 86% in open and 97% in robotic group (p = 0.04). Median intensive care unit (ICU) stay (2 days versus 5 days) and median hospital stay (10.5 days versus 14.5 days) were both favoring for robotic group (p < 0.0001). Cardiac arrhythmias and pulmonary complications requiring ICU readmission occurred less frequently in patients undergoing robotic esophagectomy (p = 0.02). Two-year overall survival (p = 0.09) and 2-year disease-free survival (p = 0.32) was similar between the groups. RAMIE significantly reduced ICU as well as hospital stay and had oncological outcome similar to open Mckeown's esophagectomy.
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Affiliation(s)
- Assif Iqbal Sayed
- Department of GI and HPB Oncosurgery, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, 110085, India
| | - Shaifali Goel
- Department of GI and HPB Oncosurgery, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, 110085, India
| | - Abhishek Aggarwal
- Department of GI and HPB Oncosurgery, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, 110085, India
| | - Shivendra Singh
- Department of GI and HPB Oncosurgery, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, 110085, India. .,Department of GI and HPB Oncosurgery, Rajiv Gandhi Cancer Institute and Research Centre, Room no 3054, Ground floor, Sector -5, Rohini, Delhi, 110085, India.
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19
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Zhuo ZG, Li G, Song TN, Alai GH, Shen X, Wang Y, Lin YD. From McKeown to Ivor Lewis, the learning curve for thoracic lymphadenectomy over the first 100 robotic esophagectomy cases: a retrospective study. J Thorac Dis 2021; 13:1543-1552. [PMID: 33841946 PMCID: PMC8024862 DOI: 10.21037/jtd-20-2862] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Lymphadenectomy is an essential but challenging part of the surgical treatment for esophageal cancer. However, the previously reported learning curve for robotic esophagectomy primarily focused on only one surgical approach (McKeown or Ivor Lewis). However, both approaches must be mastered by a mature robotic surgical team to deal with different clinical conditions and satisfy patients' needs. This study aimed to show how an experienced esophageal surgical team became proficient in both McKeown and Ivor Lewis robotic esophagectomy. Methods A retrospective review of the first 100 cases of robot-assisted minimally invasive esophagectomy (RAMIE) by a single surgical team was performed. The cumulative sum (CUSUM) analysis was used to distinguish the change point during the learning course. A subgroup analysis was performed according to a surgical approach (McKeown or Ivor Lewis) to determine the effect of experience from one surgical approach on learning the other RAMIE technique. Results According to the tendency of the CUSUM plot, the learning curve was divided into four phases. The subgroup analysis indicated the decline of the CUSUM plot in the 3rd phase originated from the start of the Ivor Lewis approach. The attending surgeon took 23 cases to achieve a significant improvement in the number of harvested thoracic lymph nodes using the McKeown approach. Regardless of the acquired experience of McKeown RAMIE, it took another 18 cases for the surgical team to achieve significant improvement in harvesting thoracic lymph nodes using the Ivor Lewis approach. Conclusions Twenty-three cases were needed for an experienced surgical team to improve thoracic lymphadenectomy results using McKeown RAMIE. There was another learning phase during the transition from McKeown to Ivor Lewis esophagectomy. Importantly, the acquired experience from performing McKeown RAMIE could shorten how long it takes to learn Ivor Lewis RAMIE.
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Affiliation(s)
- Ze-Guo Zhuo
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Gang Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.,Department of Thoracic Surgery, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, Chengdu, China
| | - Tie-Niu Song
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Gu-Ha Alai
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xu Shen
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yun Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yi-Dan Lin
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
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20
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Vetshev FP, Shestakov AL, Tadzhibova IM, Tskhovrebov AT, Bitarov TT, Shakhbanov ME. [Initial experience of robot-assisted minimally invasive McKeown esophagectomy]. Khirurgiia (Mosk) 2021:20-26. [PMID: 33570350 DOI: 10.17116/hirurgia202102120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To report our initial experience of robot-assisted McKeown esophagectomy with stapled cervical esophagogastrostomy. MATERIAL AND METHODS There were 5 robot-assisted McKeown esophagectomies in patients with benign end-staged and malignant diseases of the esophagus for the period from October 2019 to February 2020. RESULTS No conversions and intraoperative complications were observed. Mean surgery time was 406±48 min, total intraoperative blood loss - 108±45 ml. Four patients had minor complications (wound infection, atelectasis, pneumothorax) that required conservative treatment. We have controlled anastomosis in 2-3 postoperative days with water-soluble contrast, none patient had an anastomotic leakage. Mean hospital-stay was 5 days. Complete (R0) resection was accomplished in all patients with malignant neoplasms. CONCLUSIONS Our first experience showed that robot-assisted McKeown esophagectomy is a safe and feasible surgical option for esophageal diseases. Robot-assisted interventions require advanced endoscopic surgical experience.
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Affiliation(s)
- F P Vetshev
- Petrovsky Russian Research Centre of Surgery, Moscow, Russia
| | - A L Shestakov
- Petrovsky Russian Research Centre of Surgery, Moscow, Russia
| | - I M Tadzhibova
- Petrovsky Russian Research Centre of Surgery, Moscow, Russia
| | - A T Tskhovrebov
- Petrovsky Russian Research Centre of Surgery, Moscow, Russia
| | - T T Bitarov
- Petrovsky Russian Research Centre of Surgery, Moscow, Russia
| | - M E Shakhbanov
- Petrovsky Russian Research Centre of Surgery, Moscow, Russia
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21
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22
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Li B, Yang Y, Toker A, Yu B, Kang CH, Abbas G, Soukiasian HJ, Li H, Daiko H, Jiang H, Fu J, Yi J, Kernstine K, Migliore M, Bouvet M, Ricciardi S, Chao YK, Kim YH, Wang Y, Yu Z, Abbas AE, Sarkaria IS, Li Z. International consensus statement on robot-assisted minimally invasive esophagectomy (RAMIE). J Thorac Dis 2020; 12:7387-7401. [PMID: 33447428 PMCID: PMC7797844 DOI: 10.21037/jtd-20-1945] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Bin Li
- Department of Thoracic Surgery, Section of Esophageal Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yang Yang
- Department of Thoracic Surgery, Section of Esophageal Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Alper Toker
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, School of Medicine, Morgantown, WV, USA
| | - Bentong Yu
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ghulam Abbas
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, School of Medicine, Morgantown, WV, USA
| | - Harmik J Soukiasian
- Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Hecheng Li
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hiroyuki Daiko
- Department of Esophageal Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Hongjing Jiang
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Jianhua Fu
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jun Yi
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical Scholl of Nanjing University, Nanjing, China
| | - Kemp Kernstine
- Department of Cardiothoracic Surgery, UT Southwestern, Dallas, TX, USA
| | - Marcello Migliore
- Section of Thoracic Surgery, Department of Surgery and Medical Specialties, Policlinico University Hospital, University of Catania, Catania, Italy
| | - Michael Bouvet
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Sara Ricciardi
- Division of Thoracic Surgery, Department of Surgical, Medical, Molecular, Pathology and Critical Care, University Hospital of Pisa, Pisa, Italy
| | - Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan
| | - Yong-Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yun Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhentao Yu
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Abbas E Abbas
- Division of Thoracic Surgery, Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Inderpal S Sarkaria
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Zhigang Li
- Department of Thoracic Surgery, Section of Esophageal Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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23
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Chen H, Lee H, Liao M, Chang T, Lin C, Liao L, Chen K. The clinical and endoscopic features of esophageal ectopic sebaceous glands. ADVANCES IN DIGESTIVE MEDICINE 2020. [DOI: 10.1002/aid2.13187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hui‐Fen Chen
- Department of Gastroenterology Taipei City Hospital, Renai Branch Taipei Taiwan
| | - Hsi‐Chang Lee
- Department of Gastroenterology Taipei City Hospital, Renai Branch Taipei Taiwan
| | - Min‐Kai Liao
- Department of Gastroenterology Taipei City Hospital, Renai Branch Taipei Taiwan
| | - Ting‐An Chang
- Department of Pathology Taipei City Hospital, Renai Branch Taipei Taiwan
| | - Chih‐Lin Lin
- Department of Gastroenterology Taipei City Hospital, Renai Branch Taipei Taiwan
| | - Li‐Ying Liao
- Department of Gastroenterology Taipei City Hospital, Renai Branch Taipei Taiwan
| | - Kuan‐Yang Chen
- Department of Gastroenterology Taipei City Hospital, Renai Branch Taipei Taiwan
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24
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Tsunoda S, Obama K, Hisamori S, Nishigori T, Okamura R, Maekawa H, Sakai Y. Lower Incidence of Postoperative Pulmonary Complications Following Robot-Assisted Minimally Invasive Esophagectomy for Esophageal Cancer: Propensity Score-Matched Comparison to Conventional Minimally Invasive Esophagectomy. Ann Surg Oncol 2020; 28:639-647. [PMID: 32892268 DOI: 10.1245/s10434-020-09081-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/12/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Whether robot-assisted minimally invasive surgery (RAMIE) is more beneficial than conventional minimally invasive surgery (MIE) remains unclear. METHODS In total, 165 consecutive patients with esophageal carcinoma who underwent esophagectomy between January 2015 and April 2020 were retrospectively assessed. A 1:1 propensity score matching analysis was performed to compare the short-term outcomes between RAMIE and conventional MIE. RESULTS After matching, 45 patients were included in the RAMIE and conventional MIE groups. RAMIE had a significantly longer total operative time (708 vs. 612 min, P < 0.001) and thoracic operative time (348 vs. 285 min, P < 0.001) than conventional MIE. However, there were no significant differences in terms of oncological outcomes, such as R0 resection rate and number of resected lymph nodes. The overall postoperative morbidity (Clavien-Dindo [C-D] grade II or higher) rate of RAMIE and conventional MIE were 51% and 73% (P = 0.03), respectively, and the severe postoperative morbidity (C-D grade III or higher) rates were 11% and 29% (P = 0.04), respectively. The incidence rate of recurrent laryngeal nerve palsy was halved in RAMIE (7%) compared with conventional MIE (20%) (P = 0.06). Finally, the pulmonary complication rate (18%) was significantly lower in patients who underwent RAMIE than in those who underwent conventional MIE (44%) (P = 0.006). CONCLUSIONS RAMIE was safe and feasible, even during the early period of its application at a specialized center. Moreover, it may be a promising alternative to conventional MIE, with better short-term outcomes, including significantly lower incidence of pulmonary complications.
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Affiliation(s)
- Shigeru Tsunoda
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Kazutaka Obama
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shigeo Hisamori
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tatsuto Nishigori
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Patients Safety Unit, Kyoto University Hospital, Kyoto, Japan
| | - Ryosuke Okamura
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hisatsugu Maekawa
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshiharu Sakai
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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25
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Hashimoto H, Horiuchi H, Miura S, Takayanagi S, Gunji T, Morikawa T. Clinicopathologic Characteristics of Esophageal Ectopic Sebaceous Glands: Chronological Changes and Immunohistochemical Analysis. Int J Surg Pathol 2020; 29:378-384. [PMID: 32844680 DOI: 10.1177/1066896920951844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Esophageal ectopic sebaceous glands are very rare lesions. A series of 5 cases in a single report has been the maximum number described in the English literature to date. We conducted a clinicopathologic study of 8 cases of esophageal ectopic sebaceous glands. The median patient age at the time of diagnosis was 60 years (range, 50-71 years), and 7 of the 8 patients were male. A focal lesion was observed in 7 cases, whereas 1 case exhibited multiple lesions throughout the esophagus. Four patients had previously undergone upper gastrointestinal endoscopy; in 3 patients, the focal lesion had not been detected. After diagnosis, 3 cases showed spontaneous regression at least once. Immunohistochemically, sebocytes of all 8 cases were negative for the estrogen receptor (ER) and the progesterone receptor (PgR), whereas sebocytes of 5 cases were positive for the androgen receptor (AR). Basal/parabasal cells were positive for AR, ER, and PgR in 5, 7, and 4 cases, respectively. GATA3 was expressed in the sebocytes and basal/parabasal cells of 6 out of 7 available cases, whereas all of 7 available cases were negative for mammaglobin and GCDFP15. Our report provides the basic clinicopathologic characteristics of esophageal ectopic sebaceous glands by the largest case series reported in English literature to date. Furthermore, the chronological changes, particularly spontaneous regression, and immunohistochemical expression of hormone receptors and GATA3 are compatible with lesions resulting from congenital misplacement under hormonal regulation. Therefore, they seem to be congenital misplacements detectable as a result of hormonal stimulated growth.
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Affiliation(s)
- Hirotsugu Hashimoto
- NTT Medical Center Tokyo, Tokyo, Japan.,Tokyo Healthcare University, Tokyo, Japan
| | - Hajime Horiuchi
- NTT Medical Center Tokyo, Tokyo, Japan.,Tokyo Healthcare University, Tokyo, Japan
| | | | | | | | - Teppei Morikawa
- NTT Medical Center Tokyo, Tokyo, Japan.,Tokyo Healthcare University, Tokyo, Japan
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26
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Huang YH, Chen KC, Lin SH, Huang PM, Yang PW, Lee JM. Robotic-assisted single-incision gastric mobilization for minimally invasive oesophagectomy for oesophageal cancer: preliminary results. Eur J Cardiothorac Surg 2020; 58:i65-i69. [PMID: 32617584 PMCID: PMC7594190 DOI: 10.1093/ejcts/ezaa212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES With the gradual acceptance of robotic-assisted surgery to treat oesophageal cancer and the application of a single-port approach in several abdominal procedures, we adopted a single-port technique in robotic-assisted minimally invasive oesophagectomy during the abdominal phase for gastric mobilization and abdominal lymph node dissection. METHODS Robotic-assisted oesophagectomy and mediastinal lymph node dissection in the chest were followed by robotic-assisted gastric mobilization and conduit creation with abdominal lymph node dissection, which were performed via a periumbilicus single incision. The oesophagogastrostomy was accomplished either in the chest (Ivor Lewis procedure) or neck (McKeown procedure) depending on the status of the proximal resection margin. RESULTS The procedure was successfully performed on 11 patients with oesophageal cancer from January 2017 to December 2018 in our institute. No surgical or in-hospital deaths occurred, though we had one case each of anastomotic leakage, pneumonia and hiatal hernia (9%). CONCLUSIONS Robotic single-incision gastric mobilization for minimally invasive oesophagectomy for treating oesophageal cancer seems feasible. Its value in terms of perioperative outcome and long-term survival results awaits future evaluation.
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Affiliation(s)
- Yu-Han Huang
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ke-Cheng Chen
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Sian-Han Lin
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Pei-Ming Huang
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Pei-Wen Yang
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jang-Ming Lee
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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27
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Tagkalos E, Goense L, Hoppe-Lotichius M, Ruurda JP, Babic B, Hadzijusufovic E, Kneist W, van der Sluis PC, Lang H, van Hillegersberg R, Grimminger PP. Robot-assisted minimally invasive esophagectomy (RAMIE) compared to conventional minimally invasive esophagectomy (MIE) for esophageal cancer: a propensity-matched analysis. Dis Esophagus 2020; 33:5519687. [PMID: 31206577 DOI: 10.1093/dote/doz060] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/08/2019] [Indexed: 12/11/2022]
Abstract
Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly being applied as treatment for esophageal cancer. In this study, the results of 50 RAMIE procedures were compared with 50 conventional minimally invasive esophagectomy (MIE) operations, which had been the standard treatment for esophageal cancer prior to the robotic era. Between April 2016 and March 2018, data of 100 consecutive patients with esophageal carcinoma undergoing modified Ivor Lewis esophagectomy were prospectively collected. All operations were performed by the same surgeon using an identical intrathoracic anastomotic reconstruction technique with the same perioperative management and pain control regimen. Intra-operative and postoperative complications were graded according to definitions stated by the Esophagectomy Complications Consensus Group. Data analysis was carried out with and without propensity score matching. Baseline characteristics did not show significant differences between the RAMIE and MIE group. Propensity score matching of the initial group of 100 patients resulted in two equal groups of 40 patients for each surgical approach. In the RAMIE group, the median total lymph node yield was 27 (range 13-84) compared to 23 in the MIE group (range 11-48), P = 0.053. Median intensive care unit (ICU) stay was 1 day (range 1-43) in the RAMIE group compared to 2 days (range 1-17) in the MIE group (P = 0.029). The incidence of postoperative complications was not significantly different between the two groups (P = 0.581). In this propensity-matched study comparing RAMIE to MIE, ICU stay was significantly shorter in the RAMIE group. There was a trend in improved lymphadenectomy in RAMIE.
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Affiliation(s)
- E Tagkalos
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - L Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M Hoppe-Lotichius
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - B Babic
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - E Hadzijusufovic
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - W Kneist
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - P C van der Sluis
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - H Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - R van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - P P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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28
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Chao YK, Wen YW, Chuang WY, Cerfolio RJ. Transition from video-assisted thoracoscopic to robotic esophagectomy: a single surgeon's experience. Dis Esophagus 2020; 33:5480067. [PMID: 31022725 DOI: 10.1093/dote/doz033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 03/23/2019] [Indexed: 12/11/2022]
Abstract
Lymph node dissection (LND) along the left recurrent laryngeal nerve (RLN) is a technically challenging part of esophageal cancer surgery, especially after chemoradiotherapy (CRT). Robotic surgery holds promise to increase its safety and feasibility. The aim of this study was to describe a single thoracoscopic surgeon's experience related to the transition from video-assisted esophagectomy (VATE) to robotic esophagectomy (RE)-with a special focus on the safety of left RLN LND. Patients who underwent minimally invasive esophagectomy and RLN dissection following CRT were dichotomized according to the use of robotic surgery (robotic esophagectomy [RE] versus video-assisted thoracoscopic esophagectomy [VATE]). The following parameters were determined: (1) number of dissected nodes, (2) rates of RLN palsy, (3) rates of perioperative complications, and (4) learning curve. Learning curve analysis was performed using the 10-patient moving average (MA) for operation times and with the cumulative sum (CUSUM) method for left RLN LND (target failure rate: 15%). The RE and VATE groups consisted of 39 and 67 patients, respectively. The intraoperative identification of the left RLN was more common in the RE group (97.4%) than in the VATE group (68.7%; P < 0.001). Postoperative left RLN palsy was significantly more frequent in the VATE group (26.9%) than in the RE group (10.3%; P = 0.042), with a higher rate of pneumonia in the former (16.4% versus 2.6%; P = 0.03). The MA chart revealed a downward trend followed by a flattening of the RE operation time at operation number 17 and 29, respectively. CUSUM analysis showed that the left RLN palsy rate decreased to the target rate after 12 operations. We conclude that at least 12 cases are required for a surgeon with prior experience in VATE to safely accomplish left RLN LND through a robotic approach.
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Affiliation(s)
- Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou
| | - Yu-Wen Wen
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou.,Clinical Informatics and Medical Statistics Research Center
| | - Wen-Yu Chuang
- Department of Pathology, Chang Gung Memorial Hospital-Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Robert J Cerfolio
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, USA
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29
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Abstract
Over the last few decades, minimally invasive approaches have gained in popularity for the surgical treatment of esophageal cancer, with the hopes of reducing the morbidity and mortality of this formidable procedure. The traditional McKeown approach includes thoracic esophageal dissection, abdominal mobilization of the gastric conduit and a cervical anastomosis. It presents several advantages over the Ivor Lewis approach: it is suitable for proximal tumors, allows a 3-field lymph node dissection, and avoids the morbidity associated with an intra-thoracic anastomotic leak. Here, we discuss the technical aspects of robotic-assisted minimally invasive McKeown esophagectomy (McKeown RAMIE).
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Affiliation(s)
- Shrey Patel
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Roman Petrov
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA.,Department of Surgical Oncology, Section of Thoracic Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Abbas Abbas
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA.,Department of Surgical Oncology, Section of Thoracic Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Charles Bakhos
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA.,Department of Surgical Oncology, Section of Thoracic Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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30
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van der Horst S, de Maat MFG, van der Sluis PC, Ruurda JP, van Hillegersberg R. Extended thoracic lymph node dissection in robotic-assisted minimal invasive esophagectomy (RAMIE) for patients with superior mediastinal lymph node metastasis. Ann Cardiothorac Surg 2019; 8:218-225. [PMID: 31032205 DOI: 10.21037/acs.2019.01.04] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Robot-assisted surgery may have a role in improving oncological outcomes in esophagectomy. Especially in the anatomical areas in the chest that are more difficult to reach in open surgery (including the superior mediastinum). The dexterity of the robotic instruments aid in performing a more extensive nodal dissection and the precision and detailed vision of the robotic system potentially improves staging, oncological outcomes and reduces complications (i.e., recurrent nerve palsy). In this article, we describe our experience and clinical outcomes in patients treated by robot assisted minimal invasive esophagectomy (RAMIE) in cN+ esophageal cancer patients with positive nodes localized in the superior mediastinum. Methods From May 2007-2018, all patients who had involved nodes by either fluor-18-deoxyglucose positron-emission-tomography-computed tomography (FDG-PET-CT) or endoscopic ultrasound (EUS) + fine needle aspiration (FNA) localized in the superior mediastinum (above level Th4/sternal angle) were identified. Patient characteristics, perioperative data, postoperative clinical outcomes/complications and overall survival were prospectively recorded and retrospectively evaluated. Results Forty patients (48% adenocarcinoma) met our inclusion criteria. All patients underwent a three-stage procedure with cervical anastomosis and 90% of the patients underwent neoadjuvant chemoradiotherapy. Mortality occurred in three patients (7.5%), of which two were caused by severe acute respiratory distress syndrome (ARDS). The most frequent complications were pneumonia (25%), chylothorax (20%), anastomotic leakage (17.5%) and vocal cord paralysis (17.5%) which was grade 1 in 72% of the patients. Radicality rate (R0 resection) was 98% and the average lymph node yield was 24 (range, 9-57). Median overall and disease-free survival was 26 and 17 months, respectively. Conclusions RAMIE for esophageal cancer patients with node positive disease in the superior mediastinum is associated with increased mortality/morbidity. Oncological outcome showed excellent lymph node yield, R0 rate and survival was equal compared to patients with lower mediastinal node positive disease.
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Affiliation(s)
- Sylvia van der Horst
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel F G de Maat
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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31
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Transcervical minimally invasive esophagectomy using da Vinci® SP™ Surgical System: a feasibility study in cadaveric model. Surg Endosc 2019; 33:1683-1686. [PMID: 30604262 DOI: 10.1007/s00464-018-06628-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 12/17/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND This is a preclinical cadaveric study to investigate the feasibility of transcervical esophagectomy using a novel single-port robotic surgical system. METHODS A 40-mm cervical incision was created over left supraclavicular fossa. The novel da Vinci® SP™ Surgical System was introduced through a wound retraction port. The mobilization of esophagus was performed using da Vinci SP from cervical, thoracic to abdominal segments. Lymph nodes were dissected en bloc with esophagus. RESULTS The transcervical esophagectomy with complete mobilization of the cervical, thoracic, and abdominal esophagus was completed in 60 min. The procedure was completed using the novel da Vinci SP Surgical System, which was introduced via the cranial side over the left cervical incision. No additional port was used for retraction and dissection, and the esophageal hiatus could be reached after complete transcervical dissection. CONCLUSION This preclinical study demonstrated that transcervical esophagectomy is technically feasible and can be completed with the novel da Vinci SP Surgical System without additional ports or assistance. This will serve as an important step to the performance of robotic transcervical esophagectomy without the necessity of one-lung ventilation.
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32
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Palanivelu C, Dey S, Sabnis S, Gupta R, Cumar B, Kumar S, Natarajan R, Ramakrishnan P. Robotic-assisted minimally invasive oesophagectomy for cancer: An initial experience. J Minim Access Surg 2019; 15:234-241. [PMID: 29737322 PMCID: PMC6561075 DOI: 10.4103/jmas.jmas_7_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: The morbidity related to radical oesophagectomy can be reduced by adopting minimally invasive techniques. Over 250 thoraco-laparoscopic oesophagectomy (TLE) was done in our centre over the last 15 years, before adopting robotic surgery as the latest innovation in the field of minimally invasive surgery. Here, we share our initial experience of robotic-assisted minimally invasive oesophagectomy (RAMIE) for carcinoma oesophagus. Methods: A prospective observational study conducted from February to December 2017. A total of 15 patients underwent RAMIE in this period. Data regarding demography, clinical characteristics, investigations, operating techniques, and post-operative outcome were collected in detail. Results: There were 10 (66.7%) male patients and the median age of all patients was 62.9 (range 36–78) years. The median body mass index was 24.4 (range 15–32.8) kg/m2. Twelve (80.0%) patients had squamous cell carcinoma (SCC) of the oesophagus and 3 (20%) patients had adenocarcinoma (AC). Five (33.3%) patients received neoadjuvant therapy. All 15 patients underwent RAMIE. Patients with SCC underwent McKeown's procedure, and those with AC underwent Ivor Lewis procedure. Extended two-field lymphadenectomy (including total mediastinal lymphadenectomy) was done for all the patients. The median operating time was 558 (range 390–690) min and median blood loss was 145 (range 90–230) ml. There were no intra-operative adverse events, and none of them required conversion to open or total thoracolaparoscopic procedure. The most common post-operative complications were recurrent laryngeal nerve paresis (3 patients, 20.0%) and pneumonia (2 patients, 13.3%). The median hospital stay was 9 (range 7–33) days. In total, 9 (60%) patients required adjuvant treatment. Conclusion: Adequate experience in TLE can help minimally invasive surgeons in easy adoption of RAMIE with satisfactory outcome.
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Affiliation(s)
- Chinnusamy Palanivelu
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Sumanta Dey
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Sandeep Sabnis
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Raghavendra Gupta
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Bharath Cumar
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Saravana Kumar
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Ramesh Natarajan
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Parthasarathi Ramakrishnan
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
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33
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Johncilla M, Yantiss RK. Malformations, choristomas, and hamartomas of the gastrointestinal tract and pancreas. Semin Diagn Pathol 2018; 36:24-38. [PMID: 30482417 DOI: 10.1053/j.semdp.2018.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Congenital and hamartomatous lesions of the gastrointestinal tract cause diagnostic challenges for surgical pathologists. Many of these are merely histologic curiosities, whereas others have substantial clinical implications because they herald cancer syndromes or associated anomalies. Although a comprehensive discussion of all developmental abnormalities that can occur in the gastrointestinal tract is beyond the scope of a single manuscript, some entities are more likely to be encountered by surgical pathologists, have important clinical consequences, or pose diagnostic difficulties. The purpose of this review is to discuss the more common malformations and choristomas, as well as hamartomatous lesions that may be clinically important due to their risk for cancer development, frequent associations with heritable cancer syndromes and other anomalies, or potential to simulate other entities.
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Affiliation(s)
- Melanie Johncilla
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Rhonda K Yantiss
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
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van der Werf LR, Dikken JL, van Berge Henegouwen MI, Lemmens VEPP, Nieuwenhuijzen GAP, Wijnhoven BPL. A Population-based Study on Lymph Node Retrieval in Patients with Esophageal Cancer: Results from the Dutch Upper Gastrointestinal Cancer Audit. Ann Surg Oncol 2018. [PMID: 29524046 PMCID: PMC5891559 DOI: 10.1245/s10434-018-6396-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND For esophageal cancer, the number of retrieved lymph nodes (LNs) is often used as a quality indicator. The aim of this study is to analyze the number of retrieved LNs in The Netherlands, assess factors associated with LN yield, and explore the association with short-term outcomes. This is a population-based study on lymph node retrieval in patients with esophageal cancer, presenting results from the Dutch Upper Gastrointestinal Cancer Audit. STUDY DESIGN For this retrospective national cohort study, patients with esophageal carcinoma who underwent esophagectomy between 2011 and 2016 were included. The primary outcome was the number of retrieved LNs. Univariable and multivariable regression analyses were used to test for association with ≥ 15 LNs. PATIENTS AND RESULTS 3970 patients were included. Between 2011 and 2016, the median number of LNs increased from 15 to 20. Factors independently associated with ≥ 15 LNs were: 0-10 kg preoperative weight loss (versus: unknown weight loss, odds ratio [95% confidence interval]: 0.71 [0.57-0.88]), Charlson score 0 (versus: Charlson score 2: 0.76 [0.63-0.92]), cN2 category (reference: cN0, 1.32 [1.05-1.65]), no neoadjuvant therapy and neoadjuvant chemotherapy (reference: neoadjuvant chemoradiotherapy, 1.73 [1.29-2.32] and 2.15 [1.54-3.01]), minimally invasive transthoracic (reference: open transthoracic, 1.46 [1.15-1.85]), open transthoracic (versus open and minimally invasive transhiatal, 0.29 [0.23-0.36] and 0.43 [0.32-0.59]), hospital volume of 26-50 or > 50 resections/year (reference: 0-25, 1.94 [1.55-2.42] and 3.01 [2.36-3.83]), and year of surgery [reference: 2011, odds ratios (ORs) 1.48, 1.53, 2.28, 2.44, 2.54]. There was no association of ≥ 15 LNs with short-term outcomes. CONCLUSIONS The number of LNs retrieved increased between 2011 and 2016. Weight loss, Charlson score, cN category, neoadjuvant therapy, surgical approach, year of resection, and hospital volume were all associated with increased LN yield. Retrieval of ≥ 15 LNs was not associated with increased postoperative morbidity/mortality.
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Affiliation(s)
- L R van der Werf
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - J L Dikken
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - V E P P Lemmens
- Department of Epidemiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - B P L Wijnhoven
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Jeon MS, Kim GH, Jeong DY, Park BK, Lee MW, Lee SJ, Park DY. Magnifying Endoscopy for Esophageal Ectopic Sebaceous Glands. Clin Endosc 2018; 51:495-497. [PMID: 29478307 PMCID: PMC6182283 DOI: 10.5946/ce.2017.187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 12/27/2017] [Indexed: 12/02/2022] Open
Abstract
Ectopic sebaceous glands are found very rarely in the esophagus; heretofore, several cases have been reported. The sebaceous gland is originally a source of an endodermal origin; however, there have been controversies regarding whether the origin of the esophageal ectopic sebaceous gland is ectodermal or endodermal. Ectopic sebaceous glands of the esophagus usually do not cause symptoms; thus, they are often found incidentally on endoscopy for routine health screening. Endoscopic findings are characterized by single or multiple yellow patches or nodular lesions of various sizes, sometimes with small central openings. We report two cases of esophageal ectopic sebaceous glands found incidentally during endoscopy with magnifying endoscopic findings. The lesions were in the mid-esophagus and lower esophagus, respectively, and both endoscopic findings were similar as multiple yellowish patches or plaques. Magnifying endoscopy revealed the openings of the excretory ducts surrounded by circular microvessels in both cases.
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Affiliation(s)
- Mu Song Jeon
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Dong Young Jeong
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Byeong Kyu Park
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Moon Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - So-Jeong Lee
- Department of Medicine and Pathology, Pusan National University School of Medicine, Busan, Korea
| | - Do Youn Park
- Department of Medicine and Pathology, Pusan National University School of Medicine, Busan, Korea
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