Effects of Different Anesthetic and Analgesic Methods on Cellular Immune Function and Stress Hormone Levels in Patients Undergoing Esophageal Cancer Surgery

The change of perioperative immune function in patients with esophageal cancer is mainly caused by the joint action of surgical trauma and anesthesia. In our study, we aimed to investigate the effects of different anesthetic methods on the changes of T lymphocyte subsets and cytokines in peripheral blood of patients with esophageal cancer surgery. 50 patients with esophageal cancer were divided into the study group and the control group. Among them, the patients in the control group chose intravenous anesthesia and received self-controlled intravenous analgesia after surgery. Patients in the study group chose thoracic epidural anesthesia combined with general anesthesia, undergoing self-controlled epidural analgesia after surgery; serum interleukin-2 (IL-2) and soluble interleukin-2 receptor (sIL-2R) were measured by ELISA. Serum stress hormones GH and sIL-8 were measured by radioimmunoassay. Both groups of patients achieved significant postoperative analgesia, but the VAS score in the study group at the T2-T4 time point was lower than that in the control group. The serum GH concentration in the study group increased at T1 and reached its highest peak at T2, then decreased. The serum IL-8 concentration of the two groups showed a downward trend from T1 to T4. Thoracic epidural anesthesia combined with general anesthesia for postoperative epidural analgesia can relieve the degree of cellular immunosuppression during and after surgery. Moreover, the thoracic epidural block combined with general anesthesia for esophageal cancer surgery and epidural analgesia after surgery for patients are anesthetic and analgesic methods with clinically significant effects. Our research results have a positive effect on the promotion of postoperative rehabilitation in patients with malignant cell tumors.

Robot-Assisted Minimally Invasive Esophagectomy with Intrathoracic Anastomosis (Ivor Lewis): Promising Results in 100 Consecutive Patients (the European Experience)

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.

Does Timing of Robotic Esophagectomy Adoption Impact Short-Term Postoperative Outcomes?

BACKGROUND

Robotic esophagectomies are increasingly common and are reported to have superior outcomes compared with an open approach; however, it is unclear if all institutions can achieve such outcomes. We hypothesize that early adopters of robotic technique would have improved short-term outcomes.

METHODS

The National Cancer Database (2010-2016) was used to identify robotic esophagectomies. Early adopters were defined as programs which performed robotic esophagectomies in 2010-2011, late adopters in 2012-2013. Outcomes of esophagectomies performed between 2014 and 2016 were compared and included length of stay, number of lymph nodes evaluated, readmission, conversion rate, and 90-day mortality. Multivariable regressions, accounting for robotic esophagectomy volume, were used to control for confounding factors.

RESULTS

There were 37 early adopters and 35 late adopters. Between 2014 and 2016, 683 robotic esophagectomies were performed: 446 (65.3%) by early adopters and 237 (34.7%) by late adopters. Early adopters were more likely to be academic programs (96.2 versus 72.8%, P < 0.01). Other clinical and demographic variables were similar. Late adopters were found to have decreased a number of lymph nodes evaluated (coefficient -2.407, P = 0.004) compared with early adopters. There were no significant differences in length of stay, readmissions, rate of positive margins, conversion from robotic to open, or 90-day mortality.

CONCLUSIONS

When accounting for robotic esophagectomy volume, late adoption of robotic esophagectomy was associated with a reduced lymph node harvest, but other postoperative outcomes were similar. These data suggest that programs can safely start new robotic esophagectomy programs, but must ensure an adequate case load.

A structured training pathway to implement robot-assisted minimally invasive esophagectomy: the learning curve results from a high-volume center

To ensure safe implementation of robot-assisted minimally invasive esophagectomy (RAMIE), the learning process should be optimized. This study aimed to report the results of a surgeon who implemented RAMIE in a German high-volume center by following a tailored and structured training pathway that involved proctoring. Consecutive patients who underwent RAMIE during the course of the program were included from a prospective database. A single surgeon, who had prior experience in conventional MIE, performed all RAMIE procedures. Cumulative sum (CUSUM) learning curves were plotted for the thoracic operating time and intraoperative blood loss. Perioperative outcomes were compared between patients who underwent surgery before and after a learning curve plateau occurred. Between 2017 and 2018, the adopting center adhered to the structured training pathway, and a total of 70 patients were included in the analysis. The CUSUM learning curves showed plateaus after 22 cases. In consecutive cases 23 to 70, the operating time was shorter for both the thoracic phase (median 215 vs. 249 minutes, P = 0.001) and overall procedure (median 394 vs. 440 minutes, P = 0.005), intraoperative blood loss was less (median 210 vs. 400 milliliters, P = 0.029), and lymph node yield was higher (median 32 vs. 23 nodes, P = 0.001) when compared to cases 1 to 22. No significant differences were found in terms of conversion rates, postoperative complications, length of stay, completeness of resection, or mortality. In conclusion, the structured training pathway resulted in a short and safe learning curve for RAMIE in this single center's experience. As the pathway seems effective in implementing RAMIE without compromising the early oncological outcomes and complication rates, it is advised for surgeons who are wanting to adopt this technique.

A standardized approach for the thoracic dissection in robotic-assisted minimally invasive esophagectomy (RAMIE)

Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly being adopted as the preferred surgical treatment for esophageal cancer, as it is superior to open esophagectomy and a good alternative to conventional minimally invasive esophagectomy. This paper addresses the technical details of the thoracoscopic phase of RAMIE, including the operating room set-up, patient positioning, port placement, and surgical steps.

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

OBJECTIVES

Oesophagectomy following induction chemoradiation therapy (CRT) is technically challenging. To date, little data exist to describe the feasibility of a robotic approach in this setting. In this study, we assessed national trends and outcomes of robotic oesophagectomy following induction CRT compared to the traditional open approach.

METHODS

The National Cancer Database was queried for patients who underwent oesophagectomy following induction CRT (2010-2014). Trends of robotic utilization were assessed by a Mantel-Haenszel test of trend. Propensity matching controlled for differences in age, gender, comorbidity, stage, histology and tumour location between the robotic and open groups. Overall survival was estimated by Kaplan-Meier analysis and compared by a log-rank test.

RESULTS

Oesophagectomy following induction CRT was performed in 6958 patients. Of them, 555 patients (8%) underwent robotic surgery (5% converted to an open approach). Between 2010 and 2014, utilization of a robotic approach increased from 3% to 11% (Mantel-Haenszel, P < 0.001) and the number of hospitals performing at least 1 robotic oesophagectomy increased from 23 to 57. Compared to the traditional open approach, robotic oesophagectomy was used more frequently at academic hospitals (76% vs 60%, P < 0.001), and in patients living in metropolitan areas (85% vs 77%, P < 0.001) and those living in the Midwest (41% vs 33%, P < 0.001). In the matched groups, a robotic approach was associated with shorter median hospital stay (9 vs 10 days, P = 0.004) and dissection of more lymph nodes (median, 16 vs 12, P < 0.001). However, there were no differences in rates of positive margin resection (5% for both groups, P = 0.95), 30-day readmissions (5% vs 7%, P = 0.18), 30-day mortality (2.5% vs 4%, P = 0.79), 90-day mortality (9% vs 8.5%, P = 0.89) or 5-year overall survival (42% vs 39%, P = 0.19) between patients undergoing robotic and open surgery, respectively.

CONCLUSIONS

Robotic oesophagectomy after induction CRT is feasible and associated with shorter hospitalization compared to an open approach, and does not compromise the adequacy of oncological resection, perioperative outcomes or long-term survival.

Assessment of Quality Outcomes and Learning Curve for Robot-Assisted Minimally Invasive McKeown Esophagectomy

BACKGROUND

This study aimed to identify the results of the quality assessment and the learning curve of robot-assisted minimally invasive McKeown esophagectomy (RAMIE-MK).

METHODS

The study retrospectively reviewed the data of 400 consecutive patients with esophageal cancer who underwent RAMIE-MK by a single surgeon from November 2015 to March 2019. Cumulative summation analysis of the learning curve was performed. The patients were divided into decile cohorts of 40 cases to minimize demographic deviations and to maximize the power of detecting statistically significant changes in performance.

RESULTS

The 90-day mortality rate for all the patients was 0.5% (2 cases). The authors' experience was divided into the ascending phase (40 cases), the plateau phase (175 cases), and the descending phase (185 cases). After 40 cases, significant improvements in operative time (328 vs. 251 min; P = 0.019), estimated blood loss (350 vs. 200 ml; P = 0.031), and conversion rates (12.5% vs. 2.5%; P < 0.001) were observed. After 80 cases, a decrease in the rates of anastomotic leakage (22.5% vs. 8.1%; P = 0.001) and vocal cord palsy (31.3% vs. 18.4%; P = 0.024) was observed. The number of harvested lymph nodes increased after 40 cases (13 vs. 23; P < 0.001), especially for lymph nodes along the recurrent laryngeal nerve (3.0 vs. 6.0; P < 0.001).

CONCLUSIONS

The learning phase of RAMIE-MK consists of 40 cases, and quality outcomes can be improved after 80 procedures. Several turning points related to the optimization of surgical outcomes can be used as benchmarks for surgeons performing RAMIE-MK.