Recent advances in thoracoscopic esophagectomy for esophageal cancer

[Perioperative pain therapy in minimally invasive thoracic surgery]

Thoracic surgery is often associated with severe postoperative pain levels. Even though these are less pronounced in thoracoscopic approaches, mechanical irritation, compression or injury of intercostal nerves and placement of chest tubes can cause pain levels, which must be treated. An adequate pain therapy in thoracic surgery is essential as insufficient inspiration due to inadequate analgesia may result in postoperative complications. Epidural anesthesia was considered the gold standard in thoracotomy for a long time. For video-assisted thoracoscopy, however, it is sometimes no longer recommended due to its benefit-risk ratio. Alternative thoracic blocks are the paravertebral block, the erector spinae plane block and the serratus anterior block, for which research has found heterogeneous results.This article summarizes the current recommendations for perioperative management of thoracoscopic surgery and gives an overview of the PROSPECT recommendations as well as the current Association of the Scientific Medical Societies in Germany (AWMF) guidelines for perioperative and postoperative pain therapy. In particular, individual regional anesthesia techniques and their current evidence are reviewed.

What is the best reconstruction procedure after esophagectomy? A meta-analysis comparing posterior mediastinal and retrosternal approaches

Thoracic esophagectomy is a particularly invasive and complicated surgical procedure, with a reconstruction of the gastrointestinal tract, such as the stomach, jejunum, or colon. The posterior mediastinal, retrosternal, and subcutaneous routes are the three possible esophageal reconstruction routes. Each route has advantages and disadvantages, and the optimal reconstruction route after esophagectomy remains controversial. Additionally, the best anastomotic techniques after esophagectomy in terms of location (Ivor Lewis or McKeown) and suturing (manual or mechanical) are debatable. Our meta-analysis investigating postoperative complications after esophagectomy between the posterior mediastinal and retrosternal routes revealed that the posterior mediastinal route was associated with a significantly lower anastomotic leakage rate than the retrosternal route (odds ratio = 0.78, 95% confidence interval: 0.70-0.87, p < 0.0001). Conversely, pulmonary complications (odds ratio = 0.80, 95% confidence interval: 0.58-1.11, p = 0.19) and mortality between the posterior mediastinal and retrosternal routes (odds ratio = 0.79, 95% confidence interval: 0.56-1.12, p = 0.19) were not significantly different. However, the incidence of pneumonia may be lower when using the retrosternal route rather than the posterior mediastinal route for performing minimally invasive esophagectomy. The McKeown procedure is oncologically necessary for tumors located above the carina to dissect upper mediastinal and cervical lymph nodes; however, the Ivor Lewis procedure offers perioperative and oncological safety for tumors located under the carina. An individualized treatment strategy for selecting the optimal reconstruction procedure can be proposed in future studies based on oncological and patient risk factors considering mid- to long-term quality of life.

The application of radiomics in esophageal cancer: Predicting the response after neoadjuvant therapy

Esophageal cancer (EC) is one of the fatal malignant neoplasms worldwide. Neoadjuvant therapy (NAT) combined with surgery has become the standard treatment for locally advanced EC. However, the treatment efficacy for patients with EC who received NAT varies from patient to patient. Currently, the evaluation of efficacy after NAT for EC lacks accurate and uniform criteria. Radiomics is a multi-parameter quantitative approach for developing medical imaging in the era of precision medicine and has provided a novel view of medical images. As a non-invasive image analysis method, radiomics is an inevitable trend in NAT efficacy prediction and prognosis classification of EC by analyzing the high-throughput imaging features of lesions extracted from medical images. In this literature review, we discuss the definition and workflow of radiomics, the advances in efficacy prediction after NAT, and the current application of radiomics for predicting efficacy after NAT.

Successful combined laparoscopic and thoracoscopic surgery for esophago-mediastinal fistulae

Minimally invasive surgeries have been developed, not only for gastrointestinal cancer, but also for benign or emergency cases. We report the case of a 62-year-old male who underwent laparoscopic and thoracoscopic combined surgery for an esophago-mediastinal fistula caused by a press-through package. In the initial laparoscopic phase, transhiatal dissection of the lower thoracic esophagus and harvesting of the greater omentum were performed. In the thoracoscopic phase, resection of the fistula and esophageal wall closure were performed. Thereafter, the greater omentum was lifted via the esophageal hiatus and wrapped around the repaired part of the esophagus for reinforcement. The total operative time was 371 min, with 163 and 208 min for the laparoscopic and thoracoscopic phases, respectively. In total, 20 ml of blood was lost. No perioperative complications or recurrences were observed. Laparoscopic and thoracoscopic combined omentoplasty was effective for refractory esophago-mediastinal fistula.

[Robotic-assisted Thoracic Surgery]

In the last decade robotic-assisted thoracoscopic surgery (RATS) emerged as a new minimally invasive surgical modality to operate pulmonary, mediastinal and esophageal diseases. Superior to video-assisted thoracoscopic surgery (VATS), RATS affords accurate surgical manipulation in spatially confined anatomical regions. Numerous surgical case studies demonstrated technical reliability and oncological equivalence of RATS compared to open surgery and VATS. Consequently, the number of RATS operations for oncological and non-oncological resections is rising rapidly. The lacking evidence of therapy improvement in the context of significantly increased treatment costs slows the development. Currently, various new companies introduce new robotic surgical platforms into the market and it is expected that market competition will change the costs of these modern therapies. This article summarizes the technical features of RATS and its anesthesiologic implications for patient management.

Utility of Concurrent Surgical Treatment Strategy with Thoracoscopic Esophagectomy for Patients with Synchronous Esophageal and Head and Neck Cancer

Background: Patients with esophageal squamous cell cancer (ESCC) have a high frequency to coincide with head and neck cancer (HNC). This study aims to analyze the treatment results and prognosis of patients with synchronous ESCC and HNC. Methods: From January 2016 to December 2019, 5 patients underwent concurrent surgical resection of synchronous ESCC and HNC in our institution. We retrospectively reviewed the surgical outcomes and prognosis of these patients with synchronous ESCC and HNC (HNEC group) and compared the results with those of 20 patients who underwent esophagectomy with three regional lymph node dissections for ESCC during the same period (EC group). Results: The locations of HNCs were pharynx/tongue (4/1) and the clinical stages were Stage IV in all patients. Meanwhile, the clinical stages of ESCCs were Stages 0/I/II/III (1/1/2/1). All patients underwent thoracoscopic esophagectomy. The surgical procedures concurrently performed for HNC were pharyngolaryngectomy with free jejunum transfer in 3 patients, wide tongue and mandibular segment resection with mandibular reconstruction in 1 patient, and mandibular transection with radial forearm flap reconstruction in 1 patient. There was no significant difference in the frequency of postoperative complication between these two groups. The HNEC group had a significantly shorter recurrence-free survival than the EC group (P = .046). Conclusion: Head and neck surgery with thoracoscopic esophagectomy can be safely performed concurrently with local control. The risk of recurrence is higher in ESCC patients with HNC; therefore, it is important to move on to adjuvant therapy without delay.

Early implementation of a perioperative nutrition support pathway for patients undergoing esophagectomy for esophageal cancer

Background

Unintentional weight loss and malnutrition are associated with poorer prognosis in patients with cancer. Risk of cancer‐associated malnutrition is highest among patients with esophageal cancer (EC) and has been repeatedly shown to be an independent risk factor for worse survival in these patients. Implementation of nutrition protocols may reduce postoperative weight loss and enhance recovery in these patients.

Methods

We retrospectively identified all patients who underwent Ivor Lewis esophagectomy for EC from January 2015 to August 2019 from a prospectively collected institutional database. Patients who underwent surgery after the implementation of this protocol (September 2017–August 2019) were compared with patients who underwent resection before protocol implementation (January 2015–July 2017). Patients undergoing surgery during the month of protocol initiation were excluded.

Results

Of the 404 patients included in our study, 217 were in the preprotocol group, and 187 were in the postprotocol group. Compared with the preprotocol group, there were significant reductions in length of hospital stay (p < 0.001), time to diet initiation (p < 0.001), time to feeding tube removal (p = 0.012), and postoperative weight loss (p = 0.002) in the postprotocol group. There was no significant difference in the incidence of postoperative complications, 30‐day readmission, or mortality rates between groups.

Conclusions

Results of the present study suggest a standardized perioperative nutrition protocol may prevent unintentional weight loss and improve postoperative outcomes in patients with EC undergoing resection.

Special Anesthesiologic Considerations in Robot-Assisted Thoracic Surgery

Purpose of Review

This review summarizes the key issues for preoperative, peri- and intraoperative, and postoperative patient management for robotic-assisted thoracic surgery (RATS). It provides practical guidance for anesthesiologists and thoracic surgeons starting a RATS program.

Recent Findings

RATS is a new technological approach to execute minimal invasive chest operations. In management of RATS patients, the established ERAS principles for video-assisted thoracoscopic surgery (VATS) apply. In addition, RATS imposes additional conditions on anesthesiologists, nurses, and surgeons alike: The spatial constriction in operation theaters caused by the large robotic equipment longs for a reallocation of the anesthetist’s and surgeon’s working environment that may vary additionally depending on the type of surgery performed in the individual patient. Additionally, the implementation of a positive pressure carbon dioxide gas cavity in the pleura has a direct effect on patient cardio-circulatory and respiratory mechanics that have to be balanced by the anesthesiologist.

Summary

RATS advances by replacing open surgery approaches and will complement—but most likely not replace—video-assisted thoracoscopic surgery (VATS). RATS brings new specific intraoperative requirements to the anesthesiological and surgical team members that have to be implemented into clinical routine.

The Impact of Infectious Complications after Esophagectomy for Esophageal Cancer on Cancer Prognosis and Treatment Strategy

Despite advances in the perioperative management of esophagectomy, it is still a highly invasive procedure for esophageal cancer and is associated with severe postoperative complications. The two major postoperative infectious complications after esophagectomy are pulmonary complications and anastomotic leakage. We previously reported that postoperative infectious complications after esophagectomy adversely affect long-term survival significantly in a single institution and meta-analysis. Additionally, we reviewed the mechanisms of proinflammatory cytokines, such as C-X-C motif ligand 8 (CXCL8) and its cognate receptor, C-X-C chemokine receptor 2 (CXCR2), in contributing to tumorigenesis and tumor progression. Moreover, we previously reported that introducing minimally invasive esophagectomy, including robot assistance, laparoscopic gastric mobilization, and multidisciplinary team management, significantly reduced postoperative infectious complications after esophagectomy. Further, this review also suggests future treatment strategies for esophageal cancer, considering the adverse effect of postoperative infectious complications after esophagectomy.

Status of diagnosis and treatment of esophageal cancer and non-coding RNA correlation research: a narrative review

OBJECTIVE

To describe and discuss the progression of the non-coding RNA as biomarkers in early esophageal cancer.

BACKGROUND

Esophageal cancer without obvious symptoms during early stages is one of the most common cancers, the current clinical treatments offer possibilities of a cure, but the survival rates and the prognoses remain poor, it is a serious threat to human life and health. Most patients are usually diagnosed during terminal stages due to low sensitivity of esophageal cancer's early detection techniques. With the development of molecular biology, an increasing number of non-coding RNAs are found to be associated with the occurrence, development, and prognosis of esophageal cancer. Some of these have begun to be used in clinics and laboratories for diagnosis, treatment, and prognosis, with the goal of reducing mortality.

METHODS

The information for this paper was collected from a variety of sources, including a search of the keynote's references, a search for texts in college libraries, and discussions with experts in the field of esophageal cancer clinical treatment.

CONCLUSIONS

Non-coding RNA does play a regulatory role in the development of esophageal cancer, which can predict the occurrence or prognosis of tumors, and become a new class of tumor markers and therapeutic targets in clinical applications. In this review, we survey the recent developments in the incidence, diagnosis, and treatment of esophageal cancer, especially with new research progresses on non-coding RNA biomarkers in detail, and discuss its potential clinical applications.

Comparison of laparoscopic surgery and hand-assisted laparoscopic surgery in esophagectomy: A propensity score-matched analysis

INTRODUCTION

Laparoscopic surgery (LAP) and hand-assisted laparoscopic surgery (HALS) for mobilization of the stomach and abdominal lymph node dissection in esophagectomy have become standard procedures in Japan. However, the differences in outcomes between LAP and HALS have not been examined. We aimed to compare the safety and feasibility of these techniques in patients undergoing esophagectomy.

METHODS

We assessed 171 patients who underwent esophagectomy and reconstruction for clinical stage 0 to IVa esophageal cancer; 108 patients were treated with HALS and 63 with LAP. Mortality, morbidity, and long-term survival were compared in all patients who had undergone these surgical procedures and then in 59 propensity score-matched pairs to correct for differences in baseline characteristics.

RESULTS

In our analysis, HALS had a shorter abdominal operative time (84.4 ± 26.6 vs 110.0 ± 34.1 minutes, P < .0001), but LAP enabled a larger number of abdominal lymph nodes to be harvested with (17.9 ± 6.6 vs 15.4 ± 7.4, P = .0486). The 5-year overall survival rates were 62.1% and 74.5% (P = .1257) for patients who had undergone HALS and LAP, respectively, and the relapse-free survival rates were 67.0% and 72.3% (P = .7243).

CONCLUSIONS

There were no significant differences in postoperative mortality and morbidity between the two groups. This suggests that in addition to having a short operative time, HALS has good technical feasibility and is oncologically safe for patients with esophageal cancer.

Ability of Laparoscopic Gastric Mobilization to Prevent Pulmonary Complications After Open Thoracotomy or Thoracoscopic Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-analysis

BACKGROUND

Esophagectomy has a high risk of postoperative morbidity, and pulmonary complications are the most common causes of serious morbidity. Thoracoscopic esophagectomy has been reported to reduce postoperative pulmonary complications; however, it remains unclear whether laparoscopic gastric mobilization can reduce the occurrence of postoperative pulmonary complications after open thoracotomy or thoracoscopic esophagectomy. The present meta-analysis assessed the ability of laparoscopic gastric mobilization to prevent postoperative complications after open thoracotomy or thoracoscopic esophagectomy.

METHOD

Studies reported between January 2000 and April 2019 in the PubMed and the Cochrane Library databases that analyzed the impact of laparoscopy on postoperative complications were systematically reviewed. In the meta-analysis, data were pooled and the primary outcome was postoperative pulmonary complications. The secondary outcomes were other postoperative complications, operative details, length of hospital stay and postoperative mortality.

RESULTS

A total of 13 studies (1915 patients; 1 randomized trial, 1 prospective study and 11 observational studies) were included. Laparoscopic gastric mobilization after open thoracotomy resulted in significantly reduced postoperative pulmonary complications (OR = 0.47, 95% confidence interval (CI): 0.27-0.82, p = 0.008) and postoperative mortality (OR = 0.49, 95%CI: 0.25-0.94, p = 0.03). Similarly, laparoscopic gastric mobilization after thoracoscopic esophagectomy resulted in significantly reduced postoperative pulmonary complications (OR = 0.56, 95%CI: 0.37-0.84, p = 0.005) and anastomotic leakage (OR = 0.59, 95%CI: 0.39-0.91, p = 0.02).

CONCLUSIONS

Laparoscopic gastric mobilization could be recommended for reducing postoperative pulmonary complications after esophagectomy irrespective of the thoracic approach.

Robotic Surgery in Gastrointestinal Surgery

Robotic surgery is expanding in the minimally invasive treatment of gastrointestinal cancer. In the field of gastrointestinal cancer, robotic surgery is performed using a robot-assisted surgery system. In this system, the robot does not operate automatically but is controlled by the surgeon. The surgery assistant robot currently used in clinical practice worldwide is the leader-follower type, including the da Vinci® Surgical System (Intuitive Surgical). This review describes the current state of robotic surgery in the treatment of gastrointestinal cancer and discusses the future development of robotic systems in gastrointestinal surgery.

Combined Intraoperative Identification and Monitoring of Recurrent Laryngeal Nerve Paresis during Minimally Invasive Esophagectomy: Surgical Technique Using Nerve Integrity Monitoring for Esophageal Carcinoma

Recurrent laryngeal palsy occurs after No. 106 rec RL lymphadenectomy procedure, which is assumed to cause postoperative respiratory complications. A 71-year-old Japanese man with T1b N0 M0 stage 1 esophageal cancer was scheduled for thoracoscopic esophagectomy with two-field lymph node dissection using nerve integrity monitoring (NIM). The patient demonstrated an uneventful postoperative course with 56 days remission. Under general anesthesia conditions, a single-lumen intubation tube was inserted for NIM. The automatic periodic stimulation electrode was placed on the bilateral vagus nerves on the left and right, respectively. The NIM had set and enabled the identification of the nerve accurately and continuous intraoperative nerve monitoring using impulses from the stimulation probe. The postoperative outcomes and comparison of the potential amplitudes of electromyography were observed while no postoperative vocal cord paresis was present. Combined intraoperative identification and monitoring of recurrent laryngeal nerve significantly changes the quality of the lymphadenectomy procedure and is a promising optical imaging technique. It has gained recognition for being able to reduce or prevent recurrent laryngeal nerve paralysis. It was considered a reasonable method, but it has been superseded by NIM, which is a novel technology.

Prognostic risk factors for respiratory failure after esophagectomy

Background

Esophagectomy is a high-risk surgical procedure with significant postoperative morbidity and mortality. Respiratory failure is one of the most common complications after esophageal cancer surgery. The purpose of this study was to explore risk factors that affect the recovery of respiratory failure in this kind of patients.

Methods

Totally 2,360 patients underwent esophagectomies with cervical anastomosis or intrathoracic anastomosis in our center from January 2012 to December 2017. Among them, 130 patients with respiratory failure requiring mechanical ventilation were included in the study. The Spearman’s rank correlation test and Mann-Whitney U test were performed to identify the influential factors for the duration of mechanical ventilation.

Results

Most patients (81.5%) in this study recovered in the first two weeks of mechanical ventilation, the average duration of mechanical ventilation was 10.1 days. Statistical analysis indicated that lung function test parameters such as FEV₁/FVC ratio and RV/TLC ratio could have significant influence on the duration of mechanical ventilation. The abnormally increased FEV₁/FVC ratio and RV/TLC ratio could obviously prolong the ventilation duration. Old age, thrombocytopenia, the elevated creatinine, C-reactive protein (CRP) and lactate could also significantly lengthen the duration of mechanical ventilation.

Conclusions

Abnormally increased FEV₁/FVC ratio and RV/TLC ratio as well as old age, thrombocytopenia, elevated creatinine, CRP and blood lactate were found to be risk factors for the recovery of patients with respiratory failure after esophagectomies.

The Negative Impact of Preoperative Chemotherapy on Survival After Esophagectomy for Vulnerable Elderly Patients with Esophageal Cancer

BACKGROUND

The standard treatment for patients 75 years of age or younger with cStage 2 or 3 esophageal cancer is preoperative chemotherapy followed by esophagectomy. The optimal treatment for elderly patients, especially those considered vulnerable, remains unclear.

METHODS

This study retrospectively reviewed the data for 42 patients ages 75-80 years with cStage 2 or 3 esophageal cancer who underwent esophagectomy between October 2002 and February 2019. The patients who received preoperative chemotherapy were compared with those who did not. The study also examined short- and long-term outcomes and the impact of preoperative chemotherapy on overall survival (OS) stratified by performance status (PS).

RESULTS

Of the 42 patients, 18 underwent esophagectomy without preoperative chemotherapy and 24 underwent esophagectomy after preoperative chemotherapy. A significantly greater proportion of the patients with PS 0 received preoperative chemotherapy than the patients with PS 1 (P =0.007). The multivariate analysis showed preoperative chemotherapy to be an independent negative prognostic factor for OS (hazard ratio [HR], 5.025; 95% confidence interval [CI] 1.136-22.222; P = 0.033). Subgroup analysis showed that preoperative chemotherapy had a significant negative impact on the OS of the patients with PS 1 (P < 0.001).

CONCLUSION

Preoperative chemotherapy was ineffective for the patients with PS 0 and had a significantly negative impact on the OS of the patients with PS 1. Preoperative chemotherapy should not be administered to patients 75 years of age or older with cStage 2 or 3 esophageal cancer.

Short- and mid-term outcomes of robotic versus thoraco-laparoscopic McKeown esophagectomy for squamous cell esophageal cancer: a propensity score-matched study

Controversy exists on the advantages of robotic McKeown esophagectomy (RME) versus thoraco-laparoscopic McKeown esophagectomy (TLME). The aim was to evaluate the short- and mid-term outcomes of RME and TLME in the treatment of patients with esophageal squamous cell carcinoma (ESCC). A consecutive series of 652 patients, 280 in RME and 372 in TLME, who underwent minimally invasive McKeown esophagectomy for ESCC at our department from November 2015 to June 2018 was analyzed. A propensity score-matched comparison with clinicopathological covariates was performed between the two groups. Complications were categorized based on the Esophagectomy Complications Consensus Group (ECCG) recommendation. To identify the recurrence, all patients with R0 resection were followed with a median follow-up period of 20.2 months (range 1-33 months). After propensity score matching, 271 patients were identified for each cohort. In the matched cohorts, two patients died within 90 days in TLME, whereas no patients died in RME. RME was associated with similar intraoperative blood loss (P = 0.895), but with shorter surgical duration (244.5 vs. 276.0 min, P < 0.001), shorter thoracic duration (85.0 vs. 102.9 min, P < 0.001) and lower thoracic conversions (0.7% vs. 5.9%, P = 0.001). In spite of the similar results on total and thoracic lymph nodes dissection, RME yielded more lymph nodes along recurrent laryngeal nerve (4.8 vs. 4.1, P = 0.012), as well as the higher incidence of recurrent nerve injury (29.2% vs. 15.1%, P < 0.001) when compared to TLME. Tumor recurrence occurred in 30 patients and was locoregional only in 9 (3.5%) patients, systemic only in 17 (6.7%) patients, and combined in 4 (1.6%) patients in RME, while in 26 patients and was locoregional only in 10 (10.6%) patients, systemic only in 7 (2.8%) patients, and combined in 9 (3.6%) patients in TLME. RME was associated with a lower rate of mediastinal lymph nodes recurrence (2.0% vs. 5.3%, P = 0.044). Overall and disease-free survival was not different between the two cohorts (P = 0.097 and P = 0.248, respectively). RME was shown to be a safe and oncologically effective approach with favorable short- and mid-term outcomes in the treatment of patients with ESCC.

Effectiveness and safety of bovine pericardium patch repair for cervical anastomotic leakage after oesophagectomy for cancer

Background

The objective of this study is to evaluate the effectiveness and safety of bovine pericardium patch (BPP) repair for cervical anastomotic leakage after esophageal squamous cancer.

Methods

Intractable cervical anastomotic leakage developed in 7 patients of esophageal squamous cell carcinoma undergoing cervical anastomosis. These patients received the BPP repair. The necrotic tissue around the cervical anastomosis was removed during the operation, and the defect was repaired with BPP according to the size of the leakage.

Results

The operative duration was 60-90 min (median, 75 min). There were no signs of recurrent anastomotic leakage in each patient undergoing BPP repair. Oral intake was initiated 5-8 days (median, 6 days) after the BPP repair operation without any discomfort.

Conclusions

The BPP repair is a safe and effective processing scheme for patients with cervical anastomotic fistula after resection of esophageal squamous cell carcinoma. This method may be recommended for appropriate patients with intractable cervical anastomotic fistula.

Robot-assisted esophagectomy (RAE) versus conventional minimally invasive esophagectomy (MIE) for resectable esophageal squamous cell carcinoma: protocol for a multicenter prospective randomized controlled trial (RAMIE trial, robot-assisted minimally invasive Esophagectomy)

Background

Currently, there are three main surgical approaches for resectable esophageal cancer: open transthoracic esophagectomy (OTE), conventional minimally invasive esophagectomy (MIE) and robot-assisted esophagectomy (RAE). Previous studies had demonstrated the better short-term outcomes in MIE or RAE when compared to OTE, respectively. However, to date, no prospective study was designed to compare these two minimally invasive approaches (MIE and RAE). The primary objective of this study is to compare the outcomes on survival, safety and efficacy, quality of life between RAE and MIE in the treatment for resectable esophageal squamous cell carcinoma (ESCC).

Methods

This study is designed as a multicenter, prospective, randomized, non-inferiority phase III clinical trial, investigating the safety and efficacy of RAE compared with MIE in the treatment of resectable ESCC. Eligible patients are randomly assigned to either RAE (n = 180) or MIE (n = 180) group. The follow-up visits will be scheduled at 3, 6, 9, and 12 months in the first two years, and then every 6 months until the end of the study. During the follow-up period, clinical data and quality of life questionnaires will be examined. The primary endpoint is the 5-year overall survival (OS). The secondary endpoints are 3-year OS, 5-year disease-free survival (DFS), short-term outcomes as well as quality of life.

Discussion

This is the first prospectively randomized controlled trial designed to compare RAE with MIE as surgical treatment for resectable ESCC. According to our hypothesis, RAE will result in at least similar oncologic outcomes and long-term quality of life, but with a shorter operation time, lower percentage of perioperative complications, lower blood loss, and shorter hospital stay when compared with MIE. This study started in July 2017. Follow-up will terminate after 5 years from the time when the last patient was enrolled.

Trial registration

ClinicalTrial.gov: NCT03094351 (March 29, 2017). The trial was prospectively registered.