National trends and perioperative outcomes of robotic oesophagectomy following induction chemoradiation therapy: a National Cancer Database propensity-matched analysis

Incidence and Predictors of Textbook Outcome after Minimally Invasive Esophagectomy for Cancer: A Two-Center Study

PURPOSE

The textbook outcome (TBO), a multidimensional indicator that reflects an optimal perioperative course, has emerged as a significant prognostic variable in surgical oncology. Our study aimed to assess the occurrence and determinants of TBO following minimally invasive esophagectomy (MIE) for cancer.

METHODS

A total of 945 patients who had undergone MIE at two high-volume centers between 2008 and 2022 were analyzed. Multivariable logistic regression analysis was applied to identify the independent predictors of TBO. The potential selection bias associated with choosing between different MIE techniques-namely, robotic esophagectomy (RE) and video-assisted thoracoscopic esophagectomy (VATE)-was addressed by applying inverse probability of treatment weighting (IPTW).

RESULTS

TBO was realized in 46.6% of cases (n = 440), correlating with markedly better overall and disease-free survival. Multivariable analysis showed that treatment with RE (odds ratio (OR) = 1.527; 95% confidence interval (CI) = 1.149-2.028) was associated with a higher likelihood of achieving TBO, whereas a Charlson Comorbidity Index (CCI) of 2 or higher showed an opposite association (CCI2: OR = 0.687, 95% CI = 0.483-0.977; CCI ≥ 3: OR = 0.604, 95% CI = 0.399-0.915). The advantage of RE in attaining a higher rate of TBO, compared to VATE, remained statistically significant after applying IPTW, with rates of 53.3% for RE and 42.2% for VATE. Notably, RE contributed to a greater probability of thorough lymph node dissection, resection with negative margins, and the avoidance of major complications.

CONCLUSION

TBO was realized in 46.6% of the patients who underwent MIE for cancer. Patients with a lower CCI and those who received RE were more likely to achieve TBO.

The Effect of Neoadjuvant Therapy on Esophagectomy for cT2N0M0 Esophageal Adenocarcinoma

BACKGROUND

For cT2N0M0 esophageal adenocarcinomas, the effects of neoadjuvant chemoradiotherapy (NT) on surgical outcomes and the oncological benefits to the patients are debatable. In this study, we investigated the optimal management for cT2N0M0 adenocarcinoma (1) assessing the perioperative impact of NT on esophagectomy and (2) evaluating the oncologic effect of NT in a homogeneous group of patients with clinical stage IIA. We hypothesized that NT does not negatively affect perioperative outcomes and provides an oncologic benefit to selected patients with cT2N0M0 disease.

METHODS

The National Cancer Database was queried (2010-2019) for patients with cT2N0M0 esophageal adenocarcinoma undergoing esophagectomy. After propensity-matching to adjust for differences in patient and tumor characteristics, we compared postoperative outcomes (logistic regression) and survival (Kaplan-Meier and Cox regression) among those who underwent NT vs upfront surgery (S).

RESULTS

This study included 3413 patients, of whom 2359 (69%) received NT, and 1054 (31%) S. In contrast to those who underwent S, in the matched cohort, patients treated with NT had comparable conversion rates (8% vs11.1%, p = 0.06), length of stay (9 vs 10 days, p = 0.078), unplanned readmission (5.4% vs 8.8%, p = 0.109), and 30- (3.9% vs 3.7%, p = 0.90) and 90-day mortality (5.7% vs 4.7%, p = 0.599). In addition, NT associated with improved survival in patients with cT2N0M0 tumors > 5 cm (HR 0.30, 95% CI 0.17-0.36).

CONCLUSIONS

NT does not appear to increase technical complexity or to adversely affect postoperative outcomes after esophagectomy. Furthermore, minimally invasive esophagectomy is feasible following NT, with comparable conversion rates to those who had upfront surgery. Lastly, NT was selectively associated with improved survival in patients with cT2N0M0 esophageal cancer.

Robotic Esophagectomy. A Systematic Review with Meta-Analysis of Clinical Outcomes

Background: Robot-Assisted Minimally Invasive Esophagectomy is demonstrated to be related with a facilitation in thoracoscopic procedure. To give an update on the state of art of robotic esophagectomy for cancr a systematic review with meta-analysis has been performed. Methods: a search of the studies comparing robotic and laparoscopic or open esophagectomy was performed trough the medical libraries, with the search string “robotic and (oesophagus OR esophagus OR esophagectomy OR oesophagectomy)”. Outcomes were: postoperative complications rate (anastomotic leakage, bleeding, wound infection, pneumonia, recurrent laryngeal nerves paralysis, chylotorax, mortality), intraoperative outcomes (mean blood loss, operative time and conversion), oncologic outcomes (harvested nodes, R0 resection, recurrence) and recovery outcomes (length of hospital stay). Results: Robotic approach is superior to open surgery in terms of blood loss p = 0.001, wound infection rate, p = 0.002, pneumonia rate, p = 0.030 and mean number of harvested nodes, p < 0.0001 and R0 resection rate, p = 0.043. Similarly, robotic approach is superior to conventional laparoscopy in terms of mean number of harvested nodes, p = 0.001 pneumonia rate, p = 0.003. Conclusions: robotic surgery could be considered superior to both open surgery and conventional laparoscopy. These encouraging results should promote the diffusion of the robotic surgery, with the creation of randomized trials to overcome selection bias.