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Uzun E, d'Amore A, Berlth F, Mann C, Tagkalos E, Hadzijusufovic E, Lang H, Grimminger PP. Anterior gastric wall anastomosis may lead to lower rate of delayed gastric emptying after minimally invasive Ivor Lewis esophagectomy: a retrospective cohort study. Surg Endosc 2024; 38:1950-1957. [PMID: 38334779 PMCID: PMC10978725 DOI: 10.1007/s00464-024-10696-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/08/2024] [Indexed: 02/10/2024]
Abstract
INTRODUCTION In minimally invasive esophagectomy, a circular stapled anastomosis is common, but no evidence exists investigating the role of the specific localization of the anastomosis. The aim of this study is to evaluate the impact of an esophagogastrostomy on the anterior or posterior wall of the gastric conduit on the postoperative outcomes. MATERIAL AND METHODS All oncologic minimally invasive Ivor Lewis procedures, performed between 2017 and 2022, were included in this study. The cohort was divided in two groups: a) intrathoracic esophagogastrostomy on the anterior gastric wall of the conduit (ANT, n = 285, 65%) and b) on the posterior gastric wall (POST, n = 154, 35%). Clinicopathological parameters and short-term outcomes were compared between both groups by retrieving data from the prospective database. RESULTS Overall, 439 patients were included, baseline characteristics were similar in both groups, there was a higher proportion of squamous cell carcinoma in ANT (22.8% vs. 16.2%, P = 0.043). A higher rate of robotic-assisted procedures was observed in ANT (71.2% vs. 49.4%). Anastomotic leakage rate was similar in both groups (ANT 10.4% vs. POST 9.8%, P = 0.851). Overall complication rate and Clavien-Dindo > 3 complication rates were higher in POST compared to ANT: 53.2% vs. 40% (P = 0.008) and 36.9% vs. 25.7% (P = 0.014), respectively. The rate of delayed gastric emptying (20.1% vs. 7.4%, P < 0.001) and nosocomial pneumonia (22.1% vs. 14.8%, P = 0.05) was significantly higher in POST. CONCLUSION Patients undergoing minimally invasive Ivor Lewis esophagectomy with an intrathoracic circular stapled anastomosis may benefit from esophagogastrostomy on the anterior wall of the gastric conduit, in terms of lower rate of delayed gastric emptying.
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Affiliation(s)
- Eren Uzun
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Alberto d'Amore
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Felix Berlth
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Carolina Mann
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Evangelos Tagkalos
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Edin Hadzijusufovic
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Hauke Lang
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Peter Philipp Grimminger
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany.
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Capovilla G, Uzun E, Scarton A, Moletta L, Hadzijusufovic E, Provenzano L, Salvador R, Pierobon ES, Zanchettin G, Tagkalos E, Berlth F, Lang H, Valmasoni M, Grimminger PP. Minimally invasive Ivor Lewis esophagectomy in the elderly patient: a multicenter retrospective matched-cohort study. Front Oncol 2023; 13:1104109. [PMID: 37251945 PMCID: PMC10213659 DOI: 10.3389/fonc.2023.1104109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/21/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction Several studies reported the advantages of minimally invasive esophagectomy over the conventional open approach, particularly in terms of postoperative morbidity and mortality. The literature regarding the elderly population is however scarce and it is still not clear whether elderly patients may benefit from a minimally invasive approach as the general population. We sought to evaluate whether thoracoscopic/ laparoscopic (MIE) or fully robotic (RAMIE) Ivor-Lewis esophagectomy significantly reduces postoperative morbidity in the elderly population. Methods We analyzed data of patients who underwent open esophagectomy or MIE/RAMIE at Mainz University Hospital and at Padova University Hospital between 2016 and 2021. Elderly patients were defined as those ≥ 75 years old. Clinical characteristics and the postoperative outcomes were compared between elderly patients who underwent open esophagectomy or MIE/RAMIE. A 1-to-1 matched comparison was also performed. Patients < 75 years old were evaluated as a control group. Results Among elderly patients MIE/RAMIE were associated with a lower overall morbidity (39.7% vs. 62.7%, p=0.005), less pulmonary complications (32.8 vs. 56.9%, p=0.003) and a shorter hospital stay (13 vs. 18 days, p=0.03). Comparable findings were obtained after matching. Similarly, among < 75 years-old patients, a reduced morbidity (31.2% vs. 43.5%, p=0.01) and less pulmonary complications (22% vs. 36%, p=0.001) were detected in the minimally invasive group. Discussion Minimally invasive esophagectomy improves the postoperative course of elderly patients reducing the overall incidence of postoperative complications, particularly of pulmonary complications.
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Affiliation(s)
- Giovanni Capovilla
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Padova University Hospital, Padova, Italy
| | - Eren Uzun
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Alessia Scarton
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Padova University Hospital, Padova, Italy
| | - Lucia Moletta
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Padova University Hospital, Padova, Italy
| | - Edin Hadzijusufovic
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Luca Provenzano
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Padova University Hospital, Padova, Italy
| | - Renato Salvador
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Padova University Hospital, Padova, Italy
| | - Elisa Sefora Pierobon
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Padova University Hospital, Padova, Italy
| | - Gianpietro Zanchettin
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Padova University Hospital, Padova, Italy
| | - Evangelos Tagkalos
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Felix Berlth
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Michele Valmasoni
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Padova University Hospital, Padova, Italy
| | - Peter P. Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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Intrathoracic Robotic-Sewn Anastomosis During Ivor Lewis Esophagectomy for Cancer: Back to Basics? J Gastrointest Surg 2023; 27:1034-1041. [PMID: 36732403 DOI: 10.1007/s11605-023-05616-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/28/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND To assess the feasibility, clinical utility, and safety of intrathoracic robotic-sewn esophageal anastomosis (IrEA) during Ivor Lewis esophagectomy for adenocarcinoma of the lower third of the esophagus, or cancer at the gastro-esophageal junction type I (Siewert classification). METHODS A protocol for completely robotic Ivor Lewis esophagectomy (CrIE) and intrathoracic robotic-sewn anastomosis (IrEA) was established at the authors' institutions from January 2015 through December 2019. Overall surgery-related postoperative complications were analyzed. Overall survival and disease-free survival analysis were performed using standard methods. RESULTS The study population consisted of 40 patients. Median operative time was 320 min (sd 62, range 235-500 min), and conversion to open rate was 0%. Anastomotic leak rate was 10%. The mean number of examined lymph nodes (ELN) was 19 (IQR 11-29), and the mean number of positive lymph nodes (PLN) was 3 (IQR 0-5). Short- and long-term surgical and oncological outcomes were comparable at a medium follow-up of 37 months. The median overall survival was 48 months while the mean disease-free survival was 29 months. CONCLUSION This pilot series, in which an intrathoracic robotic-sewn anastomosis (IrEA) was performed during CrIE, demonstrated the safety and feasibility of this approach. Compared to the current standard of care at a high-volume center, IrEA was associated with better postoperative surgical outcomes and similar oncological outcomes to those reported worldwide today. These results call for further validation in a prospective and controlled setting to be fully incorporated into clinical practice.
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Capovilla G, Hadzijusufovic E, Tagkalos E, Froiio C, Berlth F, Mann C, Staubitz J, Uzun E, Lang H, Grimminger PP. End to side circular stapled anastomosis during robotic-assisted Ivor Lewis minimally invasive esophagectomy (RAMIE). Dis Esophagus 2022; 35:6492661. [PMID: 34979549 DOI: 10.1093/dote/doab088] [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: 10/14/2021] [Revised: 11/11/2021] [Indexed: 12/11/2022]
Abstract
Robotic-assisted minimally invasive esophagectomy (RAMIE) represents an established approach for the treatment of esophageal cancer. Aim of this study is to evaluate the feasibility and safety of our technique for performing the intrathoracic anastomosis during RAMIE.All the procedures were performed by the same surgeon using the same technique for performing the intrathoracic anastomosis. Intraoperative and postoperative outcomes were recorded. Postoperative complications were classified according to the Esophagectomy Complications Consensus Group (ECCG); the primary outcome was the evaluation of the feasibility and safety of our technique. From 2016 to 2021, 204 patients underwent Ivor Lewis RAMIE at our Center. Two patients (0.9%) were converted during the thoracic phase. The anastomosis was completed in all the other patients forming complete anastomotic rings. The median duration for the robotic-assisted thoracoscopic phase was 224 minutes. Twenty-two of the RAMIE-Ivor Lewis patients had an anastomotic leakage (10.3%). The overall 90-day postoperative mortality was 1.9%. The procedure resulted to be feasible and safe in our cohort of patients.
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Affiliation(s)
- Giovanni Capovilla
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Edin Hadzijusufovic
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Evangelos Tagkalos
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Caterina Froiio
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.,Department of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Felix Berlth
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Carolina Mann
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Julia Staubitz
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Eren Uzun
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Peter P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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Extended lower paratracheal lymph node resection during esophagectomy for cancer - safety and necessity. BMC Cancer 2022; 22:579. [PMID: 35610592 PMCID: PMC9128288 DOI: 10.1186/s12885-022-09667-1] [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: 02/18/2022] [Accepted: 05/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ideal extent of lymphadenectomy (LAD) in esophageal oncological surgery is debated. There is no evidence for improved survival after standardized paratracheal lymph node resection performing oncological esophagectomy. Lymph nodes from the lower paratracheal station are not standardly resected during 2-field Ivor-Lewis esophagectomy for esophageal cancer. The objective of this study was to evaluate the impact of lower paratracheal lymph node (LPL) resection on perioperative outcome during esophagectomy for cancer and analyze its relevance. METHODS Retrospectively, we identified 200 consecutive patients operated in our center for esophageal cancer from January 2017 - December 2019. Patients with and without lower paratracheal LAD were compared regarding demographic data, tumor characteristics, operative details, postoperative complications, tumor recurrence and overall survival. RESULTS 103 out of 200 patients received lower paratracheal lymph node resection. On average, five lymph nodes were resected in the paratracheal region and cancer infiltration was found in two patients. Those two patients suffered from neuroendocrine carcinoma and melanoma respectively. Cases with lower paratracheal lymph node yield had significantly less overall complicated procedures (p = 0.026). Regarding overall survival and recurrence rate no significant difference could be detected between both groups (p = 0.168 and 0.371 respectively). CONCLUSION The resection of lower paratracheal lymph nodes during esophagectomy remains debatable for distal squamous cell carcinoma or adenocarcinoma of the esophagus. Tumor infiltration was only found in rare cancer entities. Since resection can be performed safely, we recommend LPL resection on demand.
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Froiio C, Berlth F, Capovilla G, Tagkalos E, Hadzijusufovic E, Mann C, Lang H, Grimminger PP. Robotic-assisted surgery for esophageal submucosal tumors: a single-center case series. Updates Surg 2022; 74:1043-1054. [PMID: 35147859 PMCID: PMC9213313 DOI: 10.1007/s13304-022-01247-z] [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: 10/15/2021] [Accepted: 01/15/2022] [Indexed: 11/21/2022]
Abstract
Esophageal submucosal tumors (SMTs) are rare heterogenous clinical entities. The surgical resection can be performed in different surgical approaches. However, the robotic surgical strategy is poorly documented in the treatment of SMTs. We present our series of operated esophageal SMTs approached via robotic-assisted surgery. Six patients with symptomatic esophageal submucosal tumors underwent robotic surgery within a 3-year period. The performed procedures were robotic-assisted enucleation, robotic esophagectomy (RAMIE) and reverse hybrid robotic esophagectomy. Patients’ clinical data, intra/postoperative outcomes, and histopathological features were retrieved from the institution’s prospective database. Five of six patients were scheduled for upfront surgery: four underwent robotic enucleation (three leiomyoma and one suspected GIST) and one underwent reverse hybrid robotic esophagectomy (suspected GIST). One patient, diagnosed with GIST, was treated with neoadjuvant Imatinib therapy, before undergoing a RAMIE. No major intra-operative complications were recorded. Median length of stay was 7 days (6–50), with a longer post-operative course in patients who underwent esophagectomy. Clavien–Dindo > 3a complications occurred in two patients, aspiration pneumonia and delayed gastric emptying. The final histopathological and immuno-histochemical diagnosis were leiomyoma, well-differentiated GIST, low-grade fibromyxoid sarcoma and Schwannoma. Robotic-assisted surgery seems to be a promising option for surgical treatment strategies of benign or borderline esophageal submucosal tumors.
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Affiliation(s)
- Caterina Froiio
- Mainz University, Johannes Gutenberg Universitat Mainz, Mainz, Germany.,Department of General Surgery , IRCCS Policlinico San Donato, University of Milan , Milano, Italy
| | - Felix Berlth
- Mainz University, Johannes Gutenberg Universitat Mainz, Mainz, Germany
| | | | | | | | - Carolina Mann
- Mainz University, Johannes Gutenberg Universitat Mainz, Mainz, Germany
| | - Hauke Lang
- Mainz University, Johannes Gutenberg Universitat Mainz, Mainz, Germany
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Daiko H, Oguma J, Fujiwara H, Ishiyama K, Kurita D, Sato K, Fujita T. Robotic esophagectomy with total mediastinal lymphadenectomy using four robotic arms alone in esophageal and esophagogastric cancer (RETML-4): a prospective feasibility study. Esophagus 2021; 18:203-210. [PMID: 33037953 DOI: 10.1007/s10388-020-00788-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/30/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Robotic-assisted esophagectomy is still in the implementation phase. Robotic surgical systems refine visualization via robotically-enhanced surgical anatomy (RESA), and the stable articulated robotic arms provide precise movements. This prospective feasibility study was conducted to evaluate robotic esophagectomy with total mediastinal lymphadenectomy using four robotic arms exclusively (RETML-4). METHODS The inclusion criterion was clinical stage I-IIIB esophageal cancer with stable general condition. Patients were positioned hemi-prone with single-lung ventilation, and the operation table was tilted until the patient was prone. The first, second, third, and fourth robotic ports were inserted into the ninth intercostal space (ICS) on the angulus inferior scapulae line, seventh ICS on the posterior axillary line, and the fifth and third ICS on the mid-axillary line, respectively. RETML-4 was performed by precise sharp dissection in wide stable operation fields, with countertraction created by a tip-up fenestrated grasper with gauze. Esophagectomy was performed separately for the middle to lower, and upper esophagus. After mobilizing the middle to lower esophagus and performing lymph node dissection, the upper esophagus was mobilized, with bilateral lymph node dissection along the recurrent laryngeal nerves. The assistant surgeon was involved only during removing gauze and collecting harvested lymph nodes in the thorax. RESULTS RETML-4 was performed in all ten patients enrolled in 2018. The median postoperative hospital stay was 15 days, and the complication rate was 60%. Nine cases achieved R0 resection. Recurrence occurred in two cases. CONCLUSIONS RETML-4 is feasible, and may facilitate minimally invasive esophagectomy by providing precise instrument movements and RESA.
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Affiliation(s)
- Hiroyuki Daiko
- Esophageal Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan. .,Esophageal Surgery Division, National Cancer Center Hospital East, Chiba, Japan.
| | - Junya Oguma
- Esophageal Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Hisashi Fujiwara
- Esophageal Surgery Division, National Cancer Center Hospital East, Chiba, Japan
| | - Koshiro Ishiyama
- Esophageal Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Daisuke Kurita
- Esophageal Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Kazuma Sato
- Esophageal Surgery Division, National Cancer Center Hospital East, Chiba, Japan
| | - Takeo Fujita
- Esophageal Surgery Division, National Cancer Center Hospital East, Chiba, Japan
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van der Sluis PC, Tagkalos E, Hadzijusufovic E, Babic B, Uzun E, van Hillegersberg R, Lang H, Grimminger PP. Robot-Assisted Minimally Invasive Esophagectomy with Intrathoracic Anastomosis (Ivor Lewis): Promising Results in 100 Consecutive Patients (the European Experience). J Gastrointest Surg 2021; 25:1-8. [PMID: 32072382 PMCID: PMC7850999 DOI: 10.1007/s11605-019-04510-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 12/01/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Robot-assisted minimally invasive esophagectomy (RAMIE) with intrathoracic anastomosis is gaining popularity as a treatment for esophageal cancer. The aim of this study was to describe postoperative complications and short-term oncologic outcomes for RAMIE procedures using the da Vinci Xi robotic system 4-arm technique. METHODS Data of 100 consecutive patients with esophageal or gastro-esophageal junction 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. Intraoperative and postoperative complications were graded according to Esophagectomy Complications Consensus Group (ECCG) definitions. RESULTS Mean duration was 416 min (±80); 70% of patients had an uncomplicated postoperative recovery. Pulmonary complications were observed in 17% of patients. Anastomotic leakage was observed in 8% of patients. Median ICU stay was 1 day and median overall postoperative hospital stay was 11 days. The 30-day mortality was 1%; 90-day mortality was 3%. A R0 resection was reached in 92% of patients with a median number of 29 dissected lymph nodes. All patients had at least 7 months of follow-up with a median follow-up of 17 months. Median overall survival was not reached yet. CONCLUSION RAMIE with intrathoracic anastomosis (Ivor Lewis) for esophageal or gastro-esophageal junction cancer was technically feasible and safe. Postoperative complications and short-term oncologic results were comparable to the highest international standards nowadays.
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Affiliation(s)
- Pieter Christiaan van der Sluis
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, D-55131 Mainz, Germany
| | - Evangelos Tagkalos
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, D-55131 Mainz, Germany
| | - Edin Hadzijusufovic
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, D-55131 Mainz, Germany
| | - Benjamin Babic
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, D-55131 Mainz, Germany
| | - Eren Uzun
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, D-55131 Mainz, Germany
| | | | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, D-55131 Mainz, Germany ,Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Peter Philipp Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, D-55131 Mainz, Germany
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Grimminger PP, Staubitz JI, Perez D, Ghadban T, Reeh M, Scognamiglio P, Izbicki JR, Biebl M, Fuchs H, Bruns CJ, Lang H, Becker T, Egberts JH. Multicenter Experience in Robot-Assisted Minimally Invasive Esophagectomy - a Comparison of Hybrid and Totally Robot-Assisted Techniques. J Gastrointest Surg 2021; 25:2463-2469. [PMID: 34145494 PMCID: PMC8523396 DOI: 10.1007/s11605-021-05044-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/17/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Oncological esophageal surgery has evolved significantly in the last decades. From open esophagectomy over (hybrid) minimally invasive surgery, nowadays, robot-assisted minimally invasive esophagectomy (RAMIE) approaches are applied. Current techniques require an analysis of possible advantages and disadvantages indicating the direction towards a novel gold standard. METHODS Robot-assisted Ivor Lewis esophagectomies, performed in the period from April 2017 to June 2019 in five German centers (Berlin, Cologne, Hamburg, Kiel, Mainz), were included in this study. Pre-, intra-, and postoperative parameters were assessed. Cases were grouped for hybrid (H-RAMIE) versus totally robot-assisted (T-RAMIE) approaches. Postoperative parameters and complications were compared using risk ratios. RESULTS A total of 175 operations were performed as T-RAMIE and 67 as H-RAMIE. Patient age (median age 62 years) and sex (83.1% male) were similarly distributed in both groups. Median duration of esophagectomy was significantly lower in the T-RAMIE group (385 versus 427 min, p < 0.001). The risks of "overall morbidity" (32.0 versus 47.8%; risk ratio [RR], 95% confidence interval (CI): 1.5, 1.1-2.1; p = 0.026), "anastomotic leak" (10.3 versus 22.4%; RR, CI: 2.2, 1.2-4.1; p = 0.020), and "respiratory failure" (1.1 versus 7.5%; RR, CI: 6.5, 1.3-32.9; p = 0.019) were significantly higher in case of H-RAMIE. CONCLUSIONS In the five participating German centers, T-RAMIE was the preferred procedure (72.3% of operations). In comparison to H-RAMIE, T-RAMIE was associated with a significantly reduced risk of postoperative morbidity, anastomotic leak, and respiratory failure as well as a significantly reduced time necessary for esophagectomy.
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Affiliation(s)
- Peter P Grimminger
- Department of General, Visceral and Transplantation Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstrasse 1, D-55131, Mainz, Germany.
| | - Julia I Staubitz
- Department of General, Visceral and Transplantation Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - Daniel Perez
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tarik Ghadban
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pasquale Scognamiglio
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Biebl
- Department of Surgery, Charité University Hospital, Berlin, Germany
| | - Hans Fuchs
- Department of General, Visceral and Tumor Surgery, University Medical Center Cologne, Cologne, Germany
| | - Christiane J Bruns
- Department of General, Visceral and Tumor Surgery, University Medical Center Cologne, Cologne, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplantation Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - Thomas Becker
- Department for General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Hospital Schleswig Holstein, Kiel, Germany
| | - Jan-Hendrik Egberts
- Department for General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Hospital Schleswig Holstein, Kiel, Germany
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de Groot EM, Goense L, Ruurda JP, van Hillegersberg R. State of the art in esophagectomy: robotic assistance in the abdominal phase. Updates Surg 2020; 73:823-830. [PMID: 33382446 PMCID: PMC8184533 DOI: 10.1007/s13304-020-00937-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/07/2020] [Indexed: 12/15/2022]
Abstract
Over the years, robot-assisted esophagectomy gained popularity. The current literature focused mainly on robotic assistance in the thoracic phase, whereas the implementation of robotic assistance in the abdominal phase is lagging behind. Advantages of adding a robotic system to the abdominal phase include robotic stapling and the increased surgeon's independency. In terms of short-term outcomes and lymphadenectomy, robotic assistance is at least equal to laparoscopy. Yet high quality evidence to conclude on this topic remains scarce. This review focuses on the evidence of robotic assistance in the abdominal phase of esophagectomy.
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Affiliation(s)
- Eline M de Groot
- Department of Surgery, University Medical Center Utrecht, POBOX 85500, 3508 GA, Utrecht, The Netherlands.
| | - Lucas Goense
- Department of Surgery, University Medical Center Utrecht, POBOX 85500, 3508 GA, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, POBOX 85500, 3508 GA, Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, POBOX 85500, 3508 GA, Utrecht, The Netherlands.
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de Groot EM, van der Horst S, Kingma BF, Goense L, van der Sluis PC, Ruurda JP, van Hillegersberg R. Robot-assisted minimally invasive thoracolaparoscopic esophagectomy versus open esophagectomy: long-term follow-up of a randomized clinical trial. Dis Esophagus 2020; 33:6006403. [PMID: 33241302 DOI: 10.1093/dote/doaa079] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/22/2020] [Accepted: 07/04/2020] [Indexed: 12/11/2022]
Abstract
Initial results of the ROBOT, which randomized between robot-assisted minimally invasive esophagectomy (RAMIE) and open transthoracic esophagectomy (OTE), showed significantly better short-term postoperative outcomes in favor of RAMIE. However, it is not yet clarified if RAMIE is equivalent to OTE regarding long-term outcomes. The aim of this study was to report the long-term oncological results of the ROBOT trial in terms of survival and disease-free survival. This study is a follow-up study of the ROBOT trial, which was a randomized controlled trial comparing RAMIE to OTE in 112 patients with intrathoracic esophageal cancer. Both the trial protocol and short-term results were previously published. The primary outcome of the current study was 5-year overall survival. Secondary outcomes were disease-free survival and recurrence patterns. Analysis was by intention to treat. During the recruitment period, 109 patients were included in the survival analysis (RAMIE n = 54, OTE n = 55). Majority of patients had clinical stage III or IV (RAMIE 63%, OTE 55%) and received neoadjuvant chemoradiotherapy (80%). Median follow-up was 60 months (range 31-60). The combined 5-year overall survival rates for RAMIE and OTE were 41% (95% CI 27-55) and 40% (95% CI 26-53), respectively (log rank test P = 0.827). The 5-year disease-free survival rate was 42% (95% CI 28-55) in the RAMIE group and 43% (95% CI 29-57) in the OTE group (log rank test P = 0.749). Out of 104 patients, 57 (55%) developed recurrent disease detected at a median of 10 months (range 0-56) after surgery. No statistically difference in recurrence rate nor recurrence pattern was observed between both groups. Overall survival and disease-free survival of RAMIE are comparable to OTE. These results continue to support the use of robotic surgery for esophageal cancer.
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Affiliation(s)
- Eline M de Groot
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sylvia van der Horst
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B Feike Kingma
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lucas Goense
- 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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12
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Heid CA, Lopez V, Kernstine K. How I do it: robotic-assisted Ivor Lewis esophagectomy. Dis Esophagus 2020; 33:6006404. [PMID: 33241303 DOI: 10.1093/dote/doaa070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/01/2020] [Accepted: 06/15/2020] [Indexed: 12/11/2022]
Abstract
Advances in minimally invasive techniques, including robotic surgical technology, have led to improved outcomes in esophagectomy. In this article, we detail our approach to the robotic Ivor Lewis esophagectomy.
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Affiliation(s)
- Christopher A Heid
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Victor Lopez
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kemp Kernstine
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Recurrent laryngeal nerve monitoring during totally robot-assisted Ivor Lewis esophagectomy. Langenbecks Arch Surg 2020; 405:1091-1099. [PMID: 32970189 PMCID: PMC7686004 DOI: 10.1007/s00423-020-01990-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/10/2020] [Indexed: 11/16/2022]
Abstract
Purpose The robot-assisted approach for Ivor Lewis esophagectomy offers an enlarged, three-dimensional overview of the intraoperative situs. The vagal nerve (VN) can easily be detected, preserved, and intentionally resected below the separation point of the recurrent laryngeal nerve (RLN). However, postoperative vocal cord paresis can result from vagal or RLN injury during radical lymph node dissection, presenting a challenge to the operating surgeon. Methods From May to August 2019, 10 cases of robot-assisted minimally invasive esophagectomy (RAMIE) with extended 2-field lymphadenectomy, performed at the University Medical Center Mainz, were included in a prospective cohort study. Bilateral intermittent intraoperative nerve monitoring (IONM) of the RLN and VN was performed, including pre- and postoperative laryngoscopy assessment. Results Reliable mean signals of the right VN (2.57 mV/4.50 ms) and the RLN (left 1.24 mV/3.71 ms, right 0.85 mV/3.56 ms) were obtained. IONM facilitated the identification of the exact height of separation of the right RLN from the VN. There were no cases of permanent postoperative vocal paresis. Median lymph node count from the paratracheal stations was 5 lymph nodes. Conclusion IONM was feasible during RAMIE. The intraoperative identification of the RLN location contributed to the accuracy of lymph node dissection of the paratracheal lymph node stations. RLN damage and subsequent postoperative vocal cord paresis can potentially be prevented by IONM.
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van Boxel GI, Kingma BF, Voskens FJ, Ruurda JP, van Hillegersberg R. Robotic-assisted minimally invasive esophagectomy: past, present and future. J Thorac Dis 2020; 12:54-62. [PMID: 32190354 DOI: 10.21037/jtd.2019.06.75] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Esophagectomy for cancer of the esophagus is increasingly performed using minimally invasive techniques. After the introduction of minimally invasive esophagectomy (MIE) in the early 1990's, robotic-assisted techniques followed after the turn of the millennium. The advent of robotic platforms has allowed the development of robotic-assisted minimally invasive esophagectomy (RAMIE) over the past 15 years. Although recent trials have shown superior peri-operative morbidity and quality of life compared to open esophagectomy, no randomized trials have compared RAMIE to conventional MIE. This paper summarizes the current literature on RAMIE and provides an overview of expected future developments in robotic surgery.
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Affiliation(s)
- Gijsbert I van Boxel
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - B Feike Kingma
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Frank J Voskens
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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