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)

Efficacy and prognostic analysis of carbon nanotracers combined with the da Vinci robot in the treatment of esophageal cancer

BACKGROUND

Traditional methods cannot clearly visualize esophageal cancer (EC) tumor contours and metastases, which limits the clinical application of da Vinci robot-assisted surgery.

AIM

To investigate the efficacy of the da Vinci robot in combination with nanocarbon lymph node tracers in radical surgery of EC.

METHODS

In total, 104 patients with early-stage EC who were admitted to Liuzhou worker's Hospital from January 2020 to June 2023 were enrolled. The patients were assigned to an observation group (n = 52), which underwent da Vinci robot-assisted minimally invasive esophagectomy (RAMIE) with the intraoperative use of nanocarbon tracers, and a control group (n = 52), which underwent traditional surgery treatment. The operation time, intraoperative blood loss, postoperative drainage tube indwelling time, hospital stay, number of lymph nodes dissected, incidence of complications, and long-term curative effects were comparatively analyzed. The postoperative stress response C-reactive protein (CRP), cortisol, epinephrine (E) and inflammatory response interleukin (IL)-6, IL-8, IL-10, and tumor necrosis factor-alpha (TNF-α) were evaluated.

RESULTS

Compared with the control group, the observation group had significantly lower postoperative CRP, cortisol, and E levels (P < 0.05) with a milder inflammatory response, as indicated by lower IL-6, IL-10, and TNF-α levels (P < 0.05). Patients who underwent RAMIE had less intraoperative blood loss and shorter operation times and hospital stays than those who underwent traditional surgery. The average number of dissected lymph nodes, time of lymph node dissection, and mean smallest lymph node diameter were all significantly lower in the observation group (P < 0.05). The rate of postoperative complications was 5.77% in the observation group, significantly lower than the 15.38% observed in the control group. Furthermore, the lymphatic metastasis rate, reoperation rate, and 12- and 24-month cumulative mortality in the observation group were 1.92%, 0%, 0%, and 0%, respectively, all of which were significantly lower than those in the control group (P < 0.05).

CONCLUSION

The treatment of EC using the da Vinci robot combined with nanocarbon lymph node tracers can achieve good surgical outcomes and demonstrates promising clinical applications.

Occurrence and recovery of vocal cord paralysis after minimally invasive McKeown esophagectomy, risk factors, and clinical outcome

BACKGROUND

This study aimed to observe the occurrence of recurrent laryngeal nerve injury after McKeown esophagectomy for esophageal squamous cell carcinoma, as well as its recovery and influencing factors within 7 months after surgery.

METHODS

From July 2020 to July 2021, among all patients who underwent minimally invasive McKeown esophagectomy, 90 patients who developed vocal cord paralysis after surgery were included in the study. These patients underwent endoscopic vocal cord function assessment every 1 to 2 months and continued until 7 months postoperatively.

RESULTS

Among all 388 patients undergoing esophagectomy, 23.2% (90/388) of patients suffered postoperative vocal cord paralysis. Left, right, and bilateral injuries were confirmed in 73 (81.1%), 12 (13.3%), and 5 patients (5.6%), respectively. With a median recovery time being 183 days, the cumulative overall recovery rate was 65.4% at 7 months, 68.6% for the left side, 55.6% for the right, and 20.0% for bilateral injuries. In multivariable analysis, cervical paraoesophageal lymph node dissection and conventional thoracoscopic-assisted esophagectomy were demonstrated to be independent risk factors associated with non-recovery of vocal cord paralysis.

CONCLUSIONS

After intensive endoscopic follow-up, a cumulative vocal cord paralysis recovery rate of 65.4% within 7 months was observed in patients after minimally invasive McKeown esophagectomy. Cervical paraoesophageal lymph node dissection and conventional thoracoscopic-assisted esophagectomy were demonstrated to be risk factors hindering vocal cord paralysis recovery.

Robot-assisted minimally invasive esophagectomy versus minimally invasive esophagectomy for thoracic lymph node dissection in patients with squamous cell carcinoma: a retrospective comparative cohort study

Background

In Asia, esophageal squamous cell carcinoma (ESCC) accounts for more than 90% of esophageal cancer cases and can be treated with minimally invasive esophagectomy (MIE); however, MIE has certain technical limitations in resecting lymph nodes. The advantages of robot-assisted minimally invasive esophagectomy (RAMIE) surgery, such as the high-definition three-dimensional (3D) vision and the presence of the EndoWrist, facilitates movement in challenging anatomical regions. However, few studies have compared the postoperative outcomes between RAMIE with MIE for the lymph node dissection of patients with ESCC.

Methods

We identified 285 patients with ESCC who underwent surgical resection between January 2019 and April 2023. Of these patients, 270 met the screening criteria and were enrolled in our study. These patients were then divided into two groups according to the thoracic approach: MIE (n=168) or RAMIE cohort (n=102). The aim of this study was to investigate the possible advantages in terms of postoperative outcomes of RAMIE over MIE for thoracic lymph node dissection.

Results

Most patients were male (97.4%). According to the pathological-stage of esophageal cancer, 5 (1.9%), 99 (37.1%), 72 (27.0%), 82 (30.7%), and 9 (3.4%) patients were pathological-stage 0, I, II, III, and IV, respectively. The number of regional lymph node resections in the RAMIE cohort was significantly higher than that in the MIE group for the following regions: the left tracheobronchial lymph nodes (106tbL) (P<0.001), paratracheal lymph nodes [106pre] (P=0.011), the sub-longitudinal lymph nodes [107] (P<0.001), the left main bronchial lymph nodes [109L] (P<0.001), the right main bronchial lymph nodes [109R] (P<0.001), the sub-thoracic periesophageal lymph nodes [110] (P=0.004), and the supradiaphragmatic lymph nodes [111] (P<0.001). By comparing MIE cohort with RAMIE cohort, the transthoracic approach with RAMIE yielded a greater total number of thoracic lymph nodes dissected [MIE: mean 20.82, standard deviation (SD) 9.45; RAMIE: mean 26.07, SD 9.28; P<0.001] and a greater total number of lymph node groups that underwent thoracic lymph node dissection (MIE: mean 5.28, SD 1.94; RAMIE: mean 7.29, SD 1.77; P<0.001).

Conclusions

Our study shows that RAMIE may be more effective than MIE in terms of the number thoracic lymph nodes dissected and the extent of dissection. Moreover, RAMIE may be not associated with additional surgical complications.

The current application and evidence for robotic approach in abdominal surgery: A narrative literature review

The current application of robotic surgery is evolving at a high pace in the current years. The technical advantages enable several abdominal surgical procedures to be performed minimally invasive instead of open surgery. Furthermore, procedures previously performed successfully using standard laparoscopy are now performed with a robotic approach, with conflicting results. The present narrative review reports the current literature on the robotic surgical procedures typically performed in a typical Scandinavian surgical department: colorectal, hernia, hepato-biliary, and esophagogastric surgery.

Esophageal cancer - French intergroup clinical practice guidelines for diagnosis, treatments and follow-up (TNCD, SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, SFP, RENAPE, SNFCP, AFEF, SFR)

INTRODUCTION

This document is a summary of the French intergroup guidelines regarding the management of esophageal cancer (EC) published in July 2022, available on the website of the French Society of Gastroenterology (SNFGE) (www.tncd.org).

METHODS

This collaborative work was conducted under the auspices of several French medical and surgical societies involved in the management of EC. Recommendations were graded in three categories (A, B and C), according to the level of evidence found in the literature until April 2022.

RESULTS

EC diagnosis and staging evaluation are mainly based on patient's general condition assessment, endoscopy plus biopsies, TAP CT-scan and 18F FDG-PET. Surgery alone is recommended for early-stage EC, while locally advanced disease (N+ and/or T3-4) is treated with perioperative chemotherapy (FLOT) or preoperative chemoradiation (CROSS regimen) followed by immunotherapy for adenocarcinoma. Preoperative chemoradiation (CROSS regimen) followed by immunotherapy or definitive chemoradiation with the possibility of organ preservation are the two options for squamous cell carcinoma. Salvage surgery is recommended for incomplete response or recurrence after definitive chemoradiation and should be performed in an expert center. Treatment for metastatic disease is based on systemic therapy including chemotherapy, immunotherapy or combined targeted therapy according to biomarkers testing such as HER2 status, MMR status and PD-L1 expression.

CONCLUSION

These guidelines are intended to provide a personalised therapeutic strategy for daily clinical practice and are subject to ongoing optimization. Each individual case should be discussed by a multidisciplinary team.

Short-term and long-term effects of recurrent laryngeal nerve injury after robotic esophagectomy

BACKGROUND

Robot-assisted minimally invasive esophagectomy (RAMIE) was reported to have superiority in upper mediastinal lymph nodes dissection than traditional approach, but related injuries to recurrent laryngeal nerve (RLNI) cannot be avoided. Considering that there is no study centering on RLNI during robotic manipulation, this study aimed to investigate the impact of RLNI on the short-term and long-term outcomes after RAMIE.

METHODS

Patients with esophageal cancer (EC) who underwent RAMIE from June 2015 to July 2019 were collated from a prospectively maintained database. Short-term and long-term outcomes of RLNI were analyzed.

RESULTS

A total of 409 patients were included with the incidence of RLNI being 18.6% (76/409). A higher rate of postoperative pulmonary complications including pneumonia (P < 0.001) and acute respiratory distress syndrome (ARDS) (P = 0.041) was associated with RLNI, requiring more interventions for bronchoscopy airway suction (P < 0.001), tracheal reintubation (P = 0.013) and tracheostomy (P < 0.001). Patients with RLNI had a prolonged length of hospitalization and intensive care unit (ICU) stay (P < 0.001). With the median follow-up time of 48.7 (interquartile range [IQR]:27.6-60.9) months, recurrence in regional lymph nodes at mediastinum did not differ between groups (P = 0.351). Similarly, the Kaplan-Meier curves revealed no significant divergency for overall survival after RLNI (P = 0.452).

CONCLUSIONS

RLNI after robotic esophagectomy is a serious morbidity associated with an increased rate of pulmonary complications, prolonged length of hospitalization with limited influence on long-term prognosis.

Innovation in gastrointestinal surgery: the evolution of minimally invasive surgery-a narrative review

Background

Minimally invasive (MI) surgery has revolutionised surgery, becoming the standard of care in many countries around the globe. Observed benefits over traditional open surgery include reduced pain, shorter hospital stay, and decreased recovery time. Gastrointestinal surgery in particular was an early adaptor to both laparoscopic and robotic surgery. Within this review, we provide a comprehensive overview of the evolution of minimally invasive gastrointestinal surgery and a critical outlook on the evidence surrounding its effectiveness and safety.

Methods

A literature review was conducted to identify relevant articles for the topic of this review. The literature search was performed using Medical Subject Heading terms on PubMed. The methodology for evidence synthesis was in line with the four steps for narrative reviews outlined in current literature. The key words used were minimally invasive, robotic, laparoscopic colorectal, colon, rectal surgery.

Conclusion

The introduction of minimally surgery has revolutionised patient care. Despite the evidence supporting this technique in gastrointestinal surgery, several controversies remain. Here we discuss some of them; the lack of high level evidence regarding the oncological outcomes of TaTME and lack of supporting evidence for robotic colorectalrectal surgery and upper GI surgery. These controversies open pathways for future research opportunities with RCTs focusing on comparing robotic to laparoscopic with different primary outcomes including ergonomics and surgeon comfort.

Impact of Robot-Assisted Minimally Invasive Esophagectomy for Esophageal Cancer: A Propensity Score-Matched Short-Term Analysis

Background

We compared short-term clinical outcomes between robotic-assisted minimally invasive esophagectomy (RAMIE) and video-assisted thoracic esophagectomy (VATS-E) using propensity score-matched analysis.

Methods

We enrolled 114 patients with esophageal cancer who underwent esophagectomy at our institution from January 2013 to January 2022. Propensity score matching was performed to minimize selection bias between the RAMIE and VATS-E groups.

Results

After propensity score matching, 72 patients (RAMIE group, n = 36; VATS-E group, n = 36) were selected for analysis. No significant differences in clinical variables were observed between the two groups. The RAMIE group had a significantly longer thoracic operation time (313 ± 40 vs. 295 ± 35 min, P = 0.048), a higher number of right recurrent laryngeal nerve lymph nodes (4.2 ± 2.7 vs. 2.9 ± 1.9, P = 0.039), and a shorter postoperative hospital stay (23.2 ± 12.8 vs. 30.4 ± 18.6 days, P = 0.018) than the VATS-E group. The RAMIE group tended to have a lower rate of anastomotic leakage (13.9% vs. 30.6%) than the VATS-E group, although the difference was not statistically significant (P = 0.089). No significant differences were found in recurrent laryngeal nerve paralysis (11.1% vs. 13.9%, P = 0.722) or pneumonia (13.9% vs. 13.9%, P = 1.000) between the RAMIE group and the VATS-E group.

Conclusion

Although RAMIE for esophageal cancer requires a longer thoracic surgery time, it might be a feasible and safe alternative to VATS-E for treating esophageal cancer. Further analysis is needed to clarify the advantages of RAMIE over VATS-E, especially in terms of long-term surgical outcomes.

Robotic Esophagectomy Trends and Early Surgical Outcomes: The US Experience

BACKGROUND

Recent esophagectomy trends were evaluated to describe the shift in surgical approach and outcomes using The Society of Thoracic Surgeons General Thoracic Surgery Database.

METHODS

All patients who underwent an esophagectomy with gastric conduit from 2015 to 2019 were identified and analyzed according to original intended approach. After performing volume trend analysis of patients, operative outcomes were evaluated.

RESULTS

Among 10,607 patients, esophagectomy was open in 5763 (54.3%), minimally invasive (MIE) in 3524 (33.2%), and robotic (RAMIE) in 1320 (12.4%). Within 5 years, MIE and RAMIE combined rose to majority approach (open from 58% to 42% of annual volume). While MIE and RAMIE were associated with higher rates of anastomotic leak, loss of conduit, pulmonary embolus, and reoperation, R0 resection and harvested number of lymph nodes exceeded those in open approaches. Operative mortality did not differ by approach (3.21% open vs 2.72% MIE vs 2.50% RAMIE; P = .2329). On multivariable analysis, RAMIE was independently associated with higher rate of anastomotic leak compared to open (adjusted odds ratio 1.53, 95% CI 1.14-2.04), while both MIE and RAMIE had lower mean length of stay. Propensity matching of 1320 pairs found a higher risk of anastomotic leak requiring surgery for RAMIE compared with MIE (adjusted odds ratio 1.39, 95% CI 1.01-1.92).

CONCLUSIONS

In less than a decade, the dominant surgical approach in The Society of Thoracic Surgeons General Thoracic Surgery Database has become minimally invasive (RAMIE and MIE). While anastomotic leak and reoperation, more common in RAMIE, require a technical solution, these complications have not raised operative mortality. Further studies are needed to address long-term results and oncologic outcome.

Robot-assisted versus thoracolaparoscopic oesophagectomy for locally advanced oesophageal squamous cell carcinoma after neoadjuvant chemoradiotherapy

INTRODUCTION

Robot-assisted oesophagectomy (RAE) and thoracolaparoscopic oesophagectomy (TLE) are surgical techniques for the treatment of oesophageal cancer. This study aimed to compare the perioperative and mid-term outcomes of RAE versus TLE for patients with locally advanced oesophageal squamous cell carcinoma (ESCC) undergoing neoadjuvant chemoradiotherapy (nCRT).

METHODS

Consecutive patients receiving nCRT plus RAE or TLE were retrospectively included in this single-institution study from January 2016 to January 2021. Perioperative outcomes were compared and survival analysis was performed.

RESULTS

This study enrolled 251 patients, 80 (31.9%) in RAE and 171 (68.1%) in TLE. The conversion rate was equivalent in RAE versus TLE (3.8% vs 2.9%, P = 1). Median operative time in RAE was significantly shorter than that in TLE (254 vs 289 min, P < 0.001). Compared to TLE, RAE harvested more lymph nodes along the recurrent laryngeal nerve [4 (3-6) vs 3 (1-5), P < 0.001]. Overall complications were similar in RAE compared to TLE (38.8% vs 38.0%, P = 0.911). No statistically significant difference in disease-free survival (log-rank P = 0.721) or overall survival (log-rank P = 0.325) was found between groups.

CONCLUSIONS

Compared to TLE, RAE could achieve shorter operative duration and better lymph nodes dissection along the bilateral RLN for locally advanced ESCC after nCRT, with comparable short-term outcomes. A long-term survival remains to be verified.

Robot-assisted esophagectomy may improve perioperative outcome in patients with esophageal cancer – a single-center experience

Background

Although the introduction of minimally invasive surgical techniques has improved surgical outcomes in recent decades, esophagectomy for esophageal cancer is still associated with severe complications and a high mortality rate. Robot-assisted surgery is already established in certain fields and robot-assisted esophagectomy may be a possible alternative to the standard minimally invasive esophagectomy. The goal of this study was to investigate whether robot assistance in esophagectomy can improve patient outcome while maintaining good oncological control.

Material and methods

Data of all patients who underwent minimally invasive esophagectomy between January 2018 and November 2021 at University Hospital Mannheim was collected retrospectively. Patients were divided into two cohorts according to operative technique (standard minimally invasive (MIE) vs. robot-assisted esophagectomy (RAMIE), and their outcomes compared. In a separate analysis, patients were propensity score matched according to age, gender and histological diagnosis, leading to 20 matching pairs.

Results

95 patients were included in this study. Of those, 71 patients underwent robot-assisted esophagectomy and 24 patients underwent standard minimally invasive esophagectomy. Robot-assisted esophagectomy showed a lower incidence of general postoperative complications (52.1% vs. 79.2%, p=0.0198), surgical complications (42.3% vs. 75.0%, p=0.0055), a lower rate of anastomotic leakage (21.1% vs. 50.0%, p=0.0067), a lower Comprehensive Complication Index (median of 20.9 vs. 38.6, p=0.0065) as well as a shorter duration of hospital stay (median of 15 vs. 26 days, p=0.0012) and stay in the intensive care unit (median of 4 vs. 7 days, p=0.028) than standard minimally invasive surgery. After additionally matching RAMIE and MIE patients according to age, gender and diagnosis, we found significant improvement in the RAMIE group compared to the MIE group regarding the Comprehensive Complication Index (median of 20.9 vs. 38.6, p=0.0276), anastomotic leakage (20% vs. 55%, p=0.0484) and severe toxicity during neoadjuvant treatment (0 patients vs. 9 patients, p=0.005).

Conclusion

Robot-assisted surgery can significantly improve outcomes for patients with esophageal cancer. It may lead to a shorter hospital stay as well as lower rates of complications, including anastomotic leakage.

Meta-analysis of robot-assisted versus video-assisted McKeown esophagectomy for esophageal cancer

We aim to review the available literature on patients with esophageal cancer treated with robot-assisted (RAME) or video-assisted McKeown's esophagectomy (VAME), to compare the efficacy and safety of the two approaches. Original research studies that evaluated perioperative and oncologic outcomes of RAME versus VAME were identified, from January 1990 to July 2022. The 90-day mortality, the R0 resection rate, the dissected lymph nodes, the perioperative parameters, and the complications were calculated according to a fixed and a random effect model. The Q statistics and I² statistic were used to test for heterogeneity among the studies. Seven studies were included, incorporating a total of 1617 patients treated with RAME or VAME. The 90-day mortality was similar between the two groups. No difference was found regarding the R0 resection rate and the number of dissected lymph nodes. In addition, the perioperative parameters, along with the total complications were similar between RAME and VAME. Nonetheless, the incidence of postoperative pneumonia was higher in the VAME group (OR:0.67 [95% CI: 0.49, 0.93]; p = 0.02). Finally, our outcomes were further validated by sensitivity analysis including only studies performing propensity score-matched analysis. Our meta-analysis showed that RAME was equivalent to VAME in terms of safety, feasibility, and oncologic adequacy. These results should be interpreted with caution due to the small number of included studies. New Randomized Controlled trials, that are currently active, will provide further evidence with greater clarity to assess the effectiveness and safety of RAME for esophageal cancer.

Patterns of Recurrence After Robot-Assisted Minimally Invasive Esophagectomy in Esophageal Squamous Cell Carcinoma

Robot-assisted minimally invasive esophagectomy (RAMIE) has been proven to be a feasible surgical approach for esophageal squamous cell carcinoma (ESCC). This study aimed to investigate the recurrence pattern and potential risk factors after RAMIE. Consecutive patients with ESCC who received RAMIE with McKeown technique at a single Esophageal Cancer Institute from November 2015 to September 2018 were retrospectively reviewed. Patients with available data, radical resection (R0), and a minimum 2-year follow-up period were eligible for the recurrence analysis. Risk factors of recurrence were examined by logistic regression analysis. R0 resection was achieved in 95.1% of patients (310/326). Of the 298 eligible patients with a median follow-up period of 30.6 months, recurrence was recognized in 95 patients (31.9%), with 4 (1.3%) local-only, 40 (13.4%) regional-only, 44 (14.8%) hematogenous-only and 7 (2.3%) combined recurrences. Cervical lymph nodes and lungs were the most frequent sites of regional and hematogenous recurrence, respectively. The median disease-free interval until recurrence was 12.1 (range 1.7-37.6) months and 83.2% of relapses occurred within 2 years after surgery. Multivariable analysis indicated that tumor in the upper esophagus, larger tumor length and positive lymph nodes as independent risk factors for recurrence. Hematogenous recurrence is the prevailing pattern after RAMIE for ESCC. For patients with advanced disease, neoadjuvant therapy is a key factor in reducing recurrence rather than surgical approaches.

Advanced Robotic Surgery: Liver, Pancreas, and Esophagus - The State of the Art?

Background

The trend in performing robotic-assisted operations in visceral surgery has been increasing in the last decade, also reaching the challenging field of hepatic, pancreatic, and esophageal surgery. Nevertheless, solid data about advantages and disadvantages of the robotic approach are still missing. The aim of this review is to analyze the benefit and impact of robotic surgery in the field of hepatic, pancreatic, and esophageal surgery, focusing on the comparison with the conventional laparoscopic or open approach.

Summary

The well-known advantages of laparoscopic surgery in comparison to the open approach are also valid for robotic surgery, with the addition of a 3D-view camera, wristed instrumentation, and an ergonomic console. On the other hand, the use of a robotic system leads to longer operating time and higher costs. Randomized controlled trials comparing the robotic approach with the laparoscopic one are still missing.

Key Message

Recent meta-analyses show promising results of the usage of robotic systems in advanced surgical procedures, like hepatic, pancreatic, and esophageal resections. Further randomized studies are needed to validate the postulated benefit.

Robot-assisted versus video-assisted thoraco-laparoscopic McKeown's esophagectomy for esophageal cancer: a propensity score-matched analysis of minimally invasive approaches

Minimally invasive esophagectomy for esophageal cancer decreases overall complication rate and leads to faster postoperative recovery. Robot-assisted minimally invasive esophagectomy is becoming more common. Its three-dimensional view and wristed instruments may provide advantages over traditional thoraco-laparoscopic techniques. There are limited studies comparing robotic and conventional thoraco-laparoscopic esophagectomy. This study aimed to evaluate short-term outcomes of robot-assisted McKeown esophagectomy (RAME) and video-assisted McKeown esophagectomy (VAME). All consecutive patients undergoing minimally invasive McKeown esophagectomy for middle and distal third esophageal cancer between January 2016 and December 2018 at our center were included in this study. Data on baseline characteristics, pathological data and short-term outcomes were collected in a dedicated database. Postoperative complications were defined as per recommendations of Esophagectomy Complications Consensus Group. Histopathologic assessment was performed as per College of American Pathologists guidelines. Propensity score matching was performed for comparison between RAME and VAME groups using age, gender, performance status, American Society of Anesthesiologists grade, body mass index, Charlson Index, tumor location, clinical tumor stage, and neoadjuvant treatment as covariates. A total of 74 patients were included, 25 of whom underwent RAME and 49 underwent VAME. Propensity score matching on 1:1 basis produced 25 pairs of patients, comparable in terms of baseline characteristics. Total operative time and estimated blood loss was similar between the two groups. Length of hospital stay was significantly lower in RAME group. Major postoperative complications (Clavien-Dindo grade ≥ 3A) were more common in VAME group, but not statistically significant. Median number of harvested lymph nodes and R0 resection rate did not differ in between the two groups. In our experience, robot-assisted McKeown esophagectomy was comparable to video-assisted McKeown esophagectomy in terms of safety, feasibility and oncologic adequacy. Use of the robot was associated with reduced hospital stay. Further randomized controlled studies with larger patient samples are needed to compare the two.

Health-related quality of life after esophagectomy in patients with esophageal cancer

Esophageal cancer is one of the malignant tumors with the poorest prognosis. Esophagectomy, which is the mainstay of curative-intent treatments, imposes excessive surgical stress on the patients, and postoperative morbidity and mortality rates after esophagectomy remain high. On the other hand, the number of survivors after esophagectomy for esophageal cancer is increasing due to recent improvements in surgical techniques and multidisciplinary treatments for this cancer. However, esophagectomy still has a great influence on the fundamental aspect of patients' lives, that is, the health-related quality of life (HR-QOL), including their physical, emotional, and social functions in the short- and long-term postoperatively. HR-QOL is a multifactorial concept used to assess the symptoms and functional changes caused by the disease itself and treatments from the patients' perspectives. Therefore, assessing the HR-QOL of patients with esophageal cancer after esophagectomy is becoming increasingly important. However, the status of HR-QOL changes after esophagectomy has not been satisfactorily evaluated, and there is no worldwide consensus as to how the postoperative HR-QOL can be improved. This review aimed to raise awareness of healthcare providers, such as surgeons and nurses, on the importance of HR-QOL in patients with esophageal cancer after curative-intent esophagectomy by providing multifaceted information concerning the short- and long-term HR-QOLs, including the status of changes and the determinants of HR-QOL after esophagectomy, and furthermore, essential points for improvement of HR-QOL after esophagectomy.

Current status of robot-assisted minimally invasive esophagectomy: what is the real benefit?

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.

Technological implementation in General Surgery services in Spain. National survey and results

Technology is one of the pillars of surgery in the 21st century and is a key factor in achieving better surgical results. The current surgical process involves not only surgical techniques, but also a very high degree of specialisation and the knowledge and use of techniques and devices from other fields. In Spain, there are no studies published at a national level in this regard. From the Minimally Invasive Surgery and Technological Innovation section of the Spanish Association of Surgeons we have designed a study whose main objective is to evaluate the degree of technological implantation in the specialty of General Surgery in Spain, as well as to analyze the devices available in the different centres of the country. We propose to make a detailed description of the applications of these devices and techniques by areas of interest, pointing out the pathologies and procedures in which this technology is used.

Robot-assisted minimally invasive esophagectomy versus video-assisted minimally invasive esophagectomy: a systematic review and meta-analysis

Background

Robot-assisted minimally invasive esophagectomy (RAMIE) has been demonstrated to offer realistic three-dimensional visual clarity, flexible movement and so on. The high cost is the main reason hampering universal application. The aim of this study was to compare the short-term outcomes of RAMIE versus video-assisted minimally invasive esophagectomy (VAMIE).

Methods

The PubMed, EMBASE and Web of Science databases were systematically searched up to June 1, 2021, for studies comparing RAMIE and VAMIE.

Results

Nineteen studies were enrolled, which consisted of a total of 4,714 patients, including 2,306 patients in the RAMIE group and 2,408 patients in the VAMIE group. In RAMIE patients, higher numbers of total lymph nodes (MD =0.171, 95% CI: 0.086–0.255, P<0.001) and lymph nodes along the left recurrent laryngeal nerve (RLN) (MD =0.219, 95% CI: 0.097–0.340, P<0.001) were removed. In RAMIE patients in the McKown group, higher numbers of total lymph nodes (MD =0.173, 95% CI: 0.080–0.265, P<0.001) and lymph nodes along the left RLN (MD =0.220, 95% CI: 0.090–0.350, P=0.001) were removed, while in those in the ESCC group, higher numbers of total lymph nodes (MD =0.249, 95% CI: 0.091–0.407, P=0.002) and lymph nodes along the left RLN (MD =0.239, 95% CI: 0.102–0.377, P=0.001) were removed.

Discussion

This study indicated that the main advantage of RAMIE was a greater number of harvested lymph nodes, which may be beneficial to diagnosis and local control. RCTs with larger sample sizes and studies reporting long-term outcomes are needed to evaluate the advantages and disadvantages of RAMIE and VAMIE.

A safe and effective anastomotic technique for robot-assisted minimally invasive oesophagectomy: Reverse-puncture anastomosis

Background

Oesophagogastric anastomosis is mainly complicated by its tediousness. We hope to modify an oesophagogastric anastomotic technique that simplifies anastomosis.

Methods

We conducted a retrospective analysis of 57 cases executed using reverse‐puncture anastomotic (RPA) technique and 64 cases of manual purse anastomosis (MPA) technique for robot‐assisted minimally invasive oesophagectomy (RAMIE). Baseline characteristics and perioperative outcomes were analysed.

Results

There were no significant differences between the 2 groups with regards to demographic data and clinical features. All patients had R0 resection. Relative to MPA, RPA group experienced significantly shorter operation times (232.5 ± 33.84 min vs. 262.3 ± 83.94 min, p = 0.038).RPA group patients had shorter anastomotic times relative to MPA group patients (10.5 ± 3.4 min vs. 18.3 ± 4.1 min, p = 0.014). No adverse events were observed.

Conclusions

Reverse‐puncture anastomosis is safe, feasible in RAMIE. This approach has the potential to efficiently shorten the anastomotic time and ensure safe operation.

Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus minimally invasive esophagectomy for resectable esophageal adenocarcinoma, a randomized controlled trial (ROBOT-2 trial)

Background

For patients with esophageal adenocarcinoma or cancer of the gastroesophageal junction, radical esophagectomy with 2-field lymphadenectomy is the cornerstone of the multimodality treatment with curative intent. Both conventional minimally invasive esophagectomy (MIE) and robot assisted minimally invasive esophagectomy (RAMIE) were shown to be superior compared to open transthoracic esophagectomy considering postoperative complications. However, no randomized comparison exists between MIE and RAMIE in the Western World for patients with esophageal adenocarcinoma.

Methods

This is an investigator-initiated and investigator-driven multicenter randomized controlled parallel-group superiority trial. All adult patients (age ≥ 18 and ≤ 90 years) with histologically proven, surgically resectable (cT1-4a, N0–3, M0) esophageal adenocarcinoma of the intrathoracic esophagus or adenocarcinoma of the gastroesophageal junction and with European Clinical Oncology Group performance status 0, 1 or 2 will be assessed for eligibility and included after obtaining informed consent. Patients (n = 218) with resectable esophageal adenocarcinoma of the intrathoracic esophagus or adenocarcinoma of the gastroesophageal junction are randomized to either RAMIE (n = 109) or MIE (n = 109). The primary outcome of this study is the total number of resected abdominal and mediastinal lymph nodes specified per lymph node station.

Conclusion

This is the first randomized controlled trial designed to compare RAMIE to MIE as surgical treatment for resectable esophageal adenocarcinoma or adenocarcinoma of the gastroesophageal junction in the Western World. The hypothesis of the proposed study is that RAMIE will result in a higher abdominal and mediastinal lymph node yield specified per station compared to conventional MIE.

Short-term results and the primary endpoint (total number of resected abdominal and mediastinal lymph nodes per lymph node station) will be analyzed and published after discharge of the last randomized patient within this trial.

Trial registration

ClinicalTrials.gov Identifier: NCT04306458. Registered 13th March 2020, https://clinicaltrials.gov/ct2/show/NCT04306458; Date of first enrolment 18.01.2021; Target sample size 218; Recruitment status: Recruiting; Protocol version 2; Issue date 10.03.2020; Rev. 02.02.2021; Authors ET, PCvdS, PPG.

Robot-assisted thoracoscopic esophagectomy for gastrointestinal stromal tumor of the esophagus: A case report

Introduction

A gastrointestinal stromal tumor (GIST) often arises in the stomach and small intestine, while esophageal GIST is rare. The first-choice treatment is surgical resection, but there is no standard technique. Herein, we describe our experience in the treatment of esophageal GIST and discuss the usefulness of robotic esophagectomy.

Presentation of case

The patient was a 60-year-old woman, who was diagnosed with a 30 mm GIST in the middle thoracic esophagus. We underwent robot-assisted thoracoscopic esophagectomy in the prone position. The duration of the thoracoscopic part was 69 min and the total operation time was 319 min. Total blood loss was 135 ml. The patient's postoperative course was uneventful after surgery and the patient was discharged home in good condition on the 18th postoperative day.

Discussion

The prognosis of esophageal GIST was less favorable compared with gastric GIST, and due to the anatomical peculiarities of the esophagus, which surgical procedure should be performed is still under debate. Robotic surgery has several technological advantages as it provides a three-dimensional view, ten times magnification, tremor control, and ambidexterity. Therefore, Robotic-assisted minimally invasive esophagectomy (RAMIE) allows achieving for safe R0 resection of esophageal GIST.

Conclusion

RAMIE may be useful for esophageal GIST because it facilitates safe and minimally invasive surgery in a limited space of the thoracic cavity.

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There is no standard technique due to the anatomical peculiarities of the esophagus.

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We think McKeown's procedure in the prone position has some advantages from others.

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Robot surgery has a three-dimensional view, tremor control, and ambidexterity.

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RAMIE would be useful techniques in a limited space of the thoracic cavity.

Robot-Assisted Versus Conventional Minimally Invasive Esophagectomy for Resectable Esophageal Squamous Cell Carcinoma: Early Results of a Multicenter Randomized Controlled Trial: the RAMIE Trial

OBJECTIVE

To compare perioperative and long-term outcomes of robot-assisted minimally invasive esophagectomy (RAMIE) and conventional minimally invasive esophagectomy (MIE) in the treatment for patients with esophageal squamous cell carcinoma (ESCC).

SUMMARY BACKGROUND DATA

RAMIE has emerged as an alternative to traditional open or thoracoscopic approaches. Efficacy and safety of RAMIE and MIE in the surgical treatment for ESCC remains uncertain given the lack of high-level clinical evidence.

METHODS

The RAMIE trial was designed as a prospective, multicenter, randomized, controlled clinical trial that compare the efficacy and safety of RAMIE and MIE in the treatment of resectable ESCC. From August 2017 to December 2019, eligible patients were randomly assigned to receive either RAMIE or MIE performed by experienced thoracic surgeons from six high-volume centers in China. Intent-to-treat analysis was performed.

RESULTS

Significantly shorter operation time was taken in RAMIE (203.8 vs. 244.9 mins, P<0.001). Compared to MIE, RAMIE showed improved efficiency of thoracic lymph node dissection in patients who received neoadjuvant therapy (15 vs. 12, P=0.016), as well as higher achievement rate of lymph node dissection along the left recurrent laryngeal nerve (RLN) (79.5% vs. 67.6%, P=0.001). No difference was found in blood loss, conversion rate, and R0 resection. The 90-day mortality was 0.6% in each group. Overall complications were similar in RAMIE (48.6%) compared to MIE (41.8%) (RR, 1.16; 95% CI, 0.92-1.46; P=0.196). Besides, the rate of major complications (Clavien-Dindo classification ≥ III) was also comparable (12.2% vs. 10.2%, P=0.551). RAMIE showed similar incidences of pulmonary complications (13.8% vs. 14.7%; P=0.812), anastomotic leakage (12.2% vs. 11.3%; P=0.801) and vocal cord paralysis (32.6% vs. 27.1%, P=0.258) to MIE.

CONCLUSIONS

Early results demonstrate that both RAMIE and MIE are safe and feasible for the treatment of ESCC. RAMIE can achieve shorter operative duration as well as better lymph node dissection in patients who received neoadjuvant therapy. Long-term results are pending for further follow-up investigations.

TRIAL REGISTRATION

ClinicalTrial.gov Identifier: NCT03094351.

Recommendations for Surveillance and Management of Recurrent Esophageal Cancer Following Endoscopic Therapies

With advancing endoscopic technology and screening protocols for Barrett disease, more patients are being diagnosed with early-stage esophageal cancer. These early-stage patients may be amendable to endoscopic therapies, such as endomucosal resection and ablation. These therapies may minimize morbidity, but the elevated risk of recurrence cannot be overlooked. This article reports outcomes and recommendations for surveillance and management of recurrent esophageal cancer following endoscopic therapies.

Robotic-assisted Ivor Lewis esophagectomy, a review of the technique

Esophageal resection is a key component of the multidisciplinary management of esophageal cancer. Robotic-assisted minimally invasive esophagectomy is gaining widespread approval amongst few centers with promising early data. There is significant variability in the operative approach utilized by different centers and this review describes, step-by-step, the operative technique at a high-volume tertiary center. The cornerstone of management is individualized surgical approach, based on patient, tumor and technical factors. Although our approach is based on aforementioned factors, our preferred approach is an Ivor Lewis esophagectomy and this review focuses on that. The procedure is broken down into three key parts, starting with an abdominal exploration and creation of the gastric conduit, placement of jejunostomy tube, moving to thoracic mobilization and creation of the side-side 6 cm stapled esophagogastric anastomosis with a final abdominal portion to assure proper positioning of the conduit and reducing redundancy. This approach is fully robotic and a side to side anastomosis facilitates the creation of a widely patent anastomosis therefore minimizing the risk of anastomotic leaks and strictures. Our experience with minimally invasive esophagectomy, as has been previously published, is associated with a 5.1% of anastomotic leak and 7.6% of anastomotic stricture. The robotic platform further optimizes this technique and helps us safely accomplish a side to side stapled anastomosis. Superior instrument dexterity in a restricted thoracic space is facilitated by intracorporeal suturing and robotic stapling. Thus, it obviates the need for a larger thoracotomy incision, which is typically needed for an EEA anastomosis, and that is traditionally associated with higher stricture rate.

Lower local recurrence rate after robot-assisted thoracoscopic esophagectomy than conventional thoracoscopic surgery for esophageal cancer

The oncological advantages of robot-assisted thoracoscopic esophagectomy (RATE) over conventional thoracoscopic esophagectomy (TE) for thoracic esophageal cancer have yet to be verified. In this study, we retrospectively analyzed clinical data to compare the incidences of recurrence within the surgical field after RATE and TE as an indicator of local oncological control. Among 121 consecutive patients with thoracic esophageal or esophagogastric junction cancers for which thoracoscopic surgery was indicated, 51 were treated with RATE while 70 received TE. The number of lymph nodes dissected from the mediastinum, duration of the thoracic portion of the surgery, and morbidity due to postoperative complications did not differ between the two groups. However, the rate of overall local recurrence within the surgical field was significantly (P = 0.039) higher in the TE (9%) than the RATE (0%) group. Lymph node recurrence within the surgical field occurred in left recurrent nerve, left tracheobronchial, left main bronchus and thoracic paraaortic lymph nodes, which were all difficult to approach to dissect. The other two local failures occurred around the anastomotic site. This study indicates that using RATE enabled the incidence of recurrence within the surgical field to be reduced, though there were some limitations.

Technological implementation in General Surgery services in Spain. National survey and results

Technology is one of the pillars of surgery in the 21st century and is a key factor in achieving better surgical results. The current surgical process involves not only surgical techniques, but also a very high degree of specialisation and the knowledge and use of techniques and devices from other fields. In Spain, there are no studies published at a national level in this regard. From the Minimally Invasive Surgery and Technological Innovation section of the Spanish Association of Surgeons we have designed a study whose main objective is to evaluate the degree of technological implantation in the specialty of General Surgery in Spain, as well as to analyze the devices available in the different centres of the country. We propose to make a detailed description of the applications of these devices and techniques by areas of interest, pointing out the pathologies and procedures in which this technology is used.

Comparison of short-term clinical outcomes between robot-assisted minimally invasive esophagectomy and video-assisted minimally invasive esophagectomy: a systematic review and meta-analysis

Background

Though robot-assisted minimally invasive esophagectomy (RAMIE) is demonstrated to offer a better visualization and provide a fine dissection of the mediastinal structures to facilitate the complex thoracoscopic operation, the superiorities of RAMIE over MIE have not been well verified. The aim of this study was to explore the actual superiorities through comparing short-term results of RAMIE with that of MIE.

Methods

PubMed, EMBASE and web of science databases were systematically searched up to September 1, 2020 for case-controlled studies that compared RAMIE with TLMIE.

Results

Fourteen studies were identified, with a total of 2,887 patients diagnosed with esophageal cancer, including 1,435 patients subjected to RAMIE group and 1,452 patients subjected to MIE group. The operative time in RAMIE was still significantly longer than that in MIE group (OR =0.785; 95% CI, 0.618-0.952; P<0.001). The incidence of pneumonia was significantly lower in RAMIE group compared with MIE group (OR =0.677; 95% CI, 0.468-0.979; P=0.038).

Conclusions

RAMIE has the superiorities over MIE in short-term outcomes in terms of pneumonia and vocal cord palsy. Therefore, RAMIE could be considered as a standard treatment for patients with esophageal cancer.

Robot-Assisted Esophagectomy After Neoadjuvant Chemoradiation-Current Status and Future Prospects

Multimodality treatment with neoadjuvant chemoradiation followed by surgery has become the standard of care for esophageal cancer. In the recent years, there has been a shift in focus of surgical approach from open esophagectomy to minimally invasive esophagectomy. Robot-assisted esophagectomy is being performed more often in centers across the world. However, there is limited data on role of robot-assisted esophagectomy in patients who have received neoadjuvant chemoradiation. Initial reports have shown that integrating neoadjuvant therapy to robot-assisted esophagectomy is feasible and safe. With the growing popularity of robot-assisted surgery worldwide among both surgeons and patients, understanding the impact of neoadjuvant chemoradiation on the procedure and its oncological outcome seems worthwhile. In the present study, we present a review of available literature on the feasibility and safety of robot-assisted minimally invasive esophagectomy in esophageal cancer patients after neoadjuvant chemoradiation.

Robot-assisted minimally invasive esophagectomy for esophageal cancer: Meticulous surgery minimizing postoperative complications

Minimally invasive esophagectomy (MIE) has been reported to reduce postoperative complications especially pulmonary complications and have equivalent long-term survival outcomes as compared to open esophagectomy. Robot-assisted minimally invasive esophagectomy (RAMIE) using da Vinci surgical system (Intuitive Surgical, Sunnyvale, USA) is rapidly gaining attention because it helps surgeons to perform meticulous surgical procedures. McKeown RAMIE has been preferably performed in East Asia where squamous cell carcinoma which lies in more proximal esophagus than adenocarcinoma is a predominant histological type of esophageal cancer. On the other hand, Ivor Lewis RAMIE has been preferably performed in the Western countries where adenocarcinoma including Barrett esophageal cancer is the most frequent histology. Average rates of postoperative complications have been reported to be lower in Ivor Lewis RAMIE than those in McKeown RAMIE. Ivor Lewis RAMIE may get more attention for thoracic esophageal cancer. The studies comparing RAMIE and MIE where recurrent nerve lymphadenectomy was thoroughly performed reported that the rate of recurrent nerve injury is lower in RAMIE than in MIE. Recurrent nerve injury leads to serious complications such as aspiration pneumonia. It seems highly probable that RAMIE is beneficial in performing recurrent nerve lymphadenectomy. Surgery for esophageal cancer will probably be more centralized in hospitals with surgical robots, which enable accurate lymph node dissection with less complications, leading to improved outcomes for patients with esophageal cancer. RAMIE might occupy an important position in surgery for esophageal cancer.

Long-Term, Health-Related Quality of Life after Open and Robot-Assisted Ivor-Lewis Procedures-A Propensity Score-Matched Study

Esophagectomies are among the most invasive surgical procedures that highly influence health-related quality of life (HRQoL). Recent improvements have helped to achieve longer survival. Therefore, long-term postoperative HRQoL needs to be emphasized in addition to classic criterions like morbidity and mortality. We aimed to compare short and long-term HRQoL after open transthoracic esophagectomies (OTEs) and robotic-assisted minimally invasive esophagectomies (RAMIEs) in patients suffering from esophageal adenocarcinoma. Prospectively collected HRQoL-data (from the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire-C30 (EORTC QLQ-C30)) were correlated with clinical courses. Only patients suffering from minor postoperative complications (Clavien-Dindo Classification of < 2) after R0 Ivor-Lewis-procedures were included. Age, sex, body mass index (BMI), American Society of Anesthesiologists physical status-score (ASA-score), tumor stage, and perioperative therapy were used for propensity score matching (PSM). Twelve RAMIE and 29 OTE patients met the inclusion criteria. RAMIE patients reported significantly better emotional and social function while suffering from significantly less pain and less physical impairment four months after surgery. The long-term follow up confirmed the results. Long-term postoperative HRQoL and self-perception partly exceeded the levels of the healthy reference population. Minor operative trauma by robotic approaches resulted in significantly reduced physical impairments while improving HRQoL and self-perception, especially in the long-term. However, further long-term results are warranted to confirm this positive trend.

Robotic resection for esophageal cancer

Background

In the surgical treatment of esophageal cancer, complete tumor resection is the most important factor and determines long-term survival. With an increase in robotic expertise in other fields of surgery, robotic-assisted minimally invasive esophagectomy (RAMIE) was born. Currently, there is a lack of convincing data on the extent of expected benefits (perioperative and oncologic outcomes and/or quality of life). Some evidence exists that patients’ overall quality of life and physical function improves, with less fatigue and pain 3 months after surgery. We aimed to review the available literature regarding robotic esophagectomy, compare perioperative, oncologic, and quality of life outcomes with open and minimally invasive approaches, and give a brief overview of our standardized four-arm RAMIE technique and explore future directions.

Methods

A Medline (PubMed) search was conducted including the following key words: esophagectomy, minimally invasive esophagectomy, robotic esophagectomy, Ivor Lewis and McKeown. We present the history, different techniques used, outcomes, and the standardization of robotic esophagectomy.

Results

Robotic esophagectomy offers a steeper learning curve with fewer complications but comparable oncological results compared to conventional minimally invasive esophagectomy.

Conclusions

Available studies suggest that RAMIE is associated with benefits regarding length of stay, clinical outcomes, and quality of life—if patients are treated in an experienced center with a standardized technique for robotic esophagectomy—making it a potentially beneficial tool in the treatment of esophageal cancer. However, center-wide standardization and prospective data collection will be a necessity to prove superiority of robotic esophagectomy.

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.

Clinical efficacy of robot-assisted thoracoscopic surgery for posterior mediastinal neurogenic tumors

Background

Robot-assisted thoracic surgery (RATS) has an increasing usage throughout the world. This retrospective cohort study aimed to objectively compare the surgical results between video-assisted thoracic surgery (VATS) and RATS in posterior mediastinal neurogenic tumors (PMNT).

Methods

We retrospectively reviewed the clinical data of 130 patients diagnosed with posterior mediastinal neurogenic tumor between 2015 and 2018. Magnetic resonance imaging (MRI) or enhanced computed tomography scan (CT-scan) was used to locate the tumor and investigate the Adamkiewicz’s artery preoperatively. The individual surgical approach was determined by both tumor size and patient’s willings.

Results

The surgical time in RATS (43.2±12.6 min) was tended to be less than that in VATS (47.4±11.9 min) (P=0.054). Meanwhile, the estimated blood loss in RATS group (85.8±22.6 mL) was significantly less than that in VATS group (95.3±28.4 mL) (P=0.040). However, the duration of chest tube (days) and volume of drainage (mL) had no significant difference between two groups (P=0.12 and P=0.68, respectively). The postoperative hospital stay (days) of patients in RATS group (2.2±0.4 days) was significantly shorter than that in VATS group (2.4±0.6 days) (P=0.031). There were no significant differences between two groups in the incidence of the postoperative complications and adverse reactions.

Conclusions

RATS has the superiorities in terms of surgical blood loss and postoperative hospital stay over VATS for posterior mediastinal neurogenic tumor. In conclusion, RATS could be a feasible and safe way for resecting posterior mediastinal neurogenic tumor.

Essential Updates 2018/2019: Essential Updates for esophageal cancer surgery

Key papers to treatment of esophageal cancer surgery and reduction of postoperative complications after esophagectomy published between 2018 and 2019 were reviewed. Within this review there was a focus on minimally invasive esophagectomy (MIE), robot-assisted MIE (RAMIE), and centralization to high-volume center. Advantages of MIE, irrespectively of hybrid or total MIE, to prevent postoperative complications, especially pneumonia, were shown in comparison to open procedure. However, whether total MIE has evident effects or not, as compared to hybrid MIEs, still remains unclear. Differences between RAMIE and MIE were reported to be marginal, though the advantage of lymphadenectomy, especially along recurrent laryngeal nerve, has been suggested. Centralization to high-volume center evidently benefits esophageal cancer patients by improving short-term outcomes. The definition of high-volume center has not been established yet, though institutional structure and quality are thought to be important. Transmediastinal esophagectomy, currently developed, has a potential to be one radical option of MIE for esophageal cancer.

Current status of esophageal cancer treatment

Esophageal cancer (EC) remains one of the most common and aggressive diseases worldwide. This review discusses some debates in the modern management of the disease. Endoscopic procedures for early cancer (T1a−b) are now embedded in routine care and the challenge will be to more accurately select patients for endoscopic resection with or without adjuvant therapy. Perioperative multimodal therapies are associated with improved survival compared to surgery alone for locally advanced esophageal cancer. However, there is no global consensus on the optimal regimen. Furthermore, histological subtype (adenocarcinomavs. squamous cell cancer) plays a role in the choice for treatment. New studies are underway to resolve some issues. The extent of the lymphadenectomy during esophagectomy remains controversial especially after neoadjuvant chemoradiation. The ideal operation balances between limiting surgical trauma and optimizing survival. Minimally invasive esophagectomy and enhanced recovery pathways are associated with decreased morbidity and faster recovery albeit there is no consensus yet what approach should be used. Finally, immune checkpoint inhibitors present promising preliminary results in the novel treatment of advanced or metastatic EC but their widespread application in clinical practice is still awaited.