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

Is Robotic Surgery the Future for Resectable Esophageal Cancer?: A Systematic Literature Review of Oncological and Clinical Outcomes

BACKGROUND

Radical esophagectomy for resectable esophageal cancer is a major surgical intervention, associated with considerable postoperative morbidity. The introduction of robotic surgical platforms in esophagectomy may enhance advantages of minimally invasive surgery enabled by laparoscopy and thoracoscopy, including reduced postoperative pain and pulmonary complications. This systematic review aims to assess the clinical and oncological benefits of robot-assisted esophagectomy.

METHODS

A systematic literature search of the MEDLINE (PubMed), Embase and Cochrane databases was performed for studies published up to 1 August 2023. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols and was registered in the PROSPERO database (CRD42022370983). Clinical and oncological outcomes data were extracted following full-text review of eligible studies.

RESULTS

A total of 113 studies (n = 14,701 patients, n = 2455 female) were included. The majority of the studies were retrospective in nature (n = 89, 79%), and cohort studies were the most common type of study design (n = 88, 79%). The median number of patients per study was 54. Sixty-three studies reported using a robotic surgical platform for both the abdominal and thoracic phases of the procedure. The weighted mean incidence of postoperative pneumonia was 11%, anastomotic leak 10%, total length of hospitalisation 15.2 days, and a resection margin clear of the tumour was achieved in 95% of cases.

CONCLUSIONS

There are numerous reported advantages of robot-assisted surgery for resectable esophageal cancer. A correlation between procedural volume and improvements in outcomes with robotic esophagectomy has also been identified. Multicentre comparative clinical studies are essential to identify the true objective benefit on outcomes compared with conventional surgical approaches before robotic surgery is accepted as standard of practice.

Minimally invasive surgery for gastro-oesophageal junction adenocarcinoma: Current evidence and future perspectives

Minimally invasive surgery is increasingly indicated in the management of malignant disease. Although oesophagectomy is a difficult operation, with a long learning curve, there is actually a shift towards the laparoscopic/thoracoscopic/ robotic approach, due to the advantages of visualization, surgeon comfort (robotic surgery) and the possibility of the whole team to see the operation as well as and the operating surgeon. Although currently there are still many controversial topics, about the surgical treatment of patients with gastro-oesophageal junction (GOJ) adenocarcinoma, such as the type of open or minimally invasive surgical approach, the type of oesophago-gastric resection, the type of lymph node dissection and others, the minimally invasive approach has proven to be a way to reduce postoperative complications of resection, especially by decreasing pulmonary complications. The implementation of new technologies allowed the widening of the range of indications for this type of surgical approach. The short-term and long-term results, as well as the benefits for the patient - reduced surgical trauma, quick and easy recovery - offer this type of surgical treatment the premises for future development. This article reviews the updates and perspectives on the minimally invasive approach for GOJ adenocarcinoma.

The Implementation of Minimally Invasive Surgery in the Treatment of Esophageal Cancer: A Step Toward Better Outcomes?

Esophagectomy is considered the cornerstone of the radical treatment of esophageal cancer. In the past decades, minimally invasive techniques including robot-assisted approaches have become popular. The aim of minimally invasive surgery is to reduce the surgical trauma, resulting in faster recovery, reduction in complications, and better quality of life after surgery. Secondly, a more precise dissection may lead to better oncological outcomes. As such, minimally invasive esophagectomy is now seen by many as the standard surgical approach. However, evidence supporting this viewpoint is limited. This narrative review summarizes recent prospectively designed studies on minimally invasive esophagectomy.

Robot-assisted Ivor Lewis Esophagectomy (RAILE): A review of surgical techniques and clinical outcomes

In the past 20 years, robotic system has gradually found a place in esophagectomy which is a demanding procedure in the deep and narrow thoracic cavity containing crucial functional structures. Ivor Lewis esophagectomy (ILE) is a mainstream surgery type for esophagectomy and is widely accepted for its capability in lymphadenectomy and relatively mitigated trauma. As a minimally invasive technique, robot-assisted Ivor Lewis esophagectomy (RAILE) has been frequently compared with the video-assisted procedure and the traditional open procedure. However, high-quality evidence elucidating the advantages and drawbacks of RAILE is still lacking. In this article, we will review the surgical techniques, both short and long-term outcomes, the learning curve, and explicate the current progress and clinical efficacy of RAILE.

C-Reactive Protein as Predictor for Infectious Complications after Robotic and Open Esophagectomies

Introduction: The value of C-reactive protein (CRP) as a predictor of anastomotic leakage (AL) after esophagectomy has been addressed by numerous studies. Despite its increasing application, robotic esophagectomy (RAMIE) has not been considered separately yet in this context. We, therefore, aimed to evaluate the predictive value of CRP in RAMIE. Material and Methods: Patients undergoing RAMIE or completely open esophagectomy (OE) at our University Center were included. Clinical data, CRP- and Procalcitonin (PCT)-values were retrieved from a prospectively maintained database and evaluated for their predictive value for subsequent postoperative infectious complications (PIC) (AL, gastric conduit leakage or necrosis, pneumonia, empyema). Results: Three hundred and five patients (RAMIE: 160, OE: 145) were analyzed. PIC were noted in 91 patients on postoperative day (POD) 10 and 123 patients on POD 30, respectively. Median POD of diagnosis of PIC was POD 8. Post-operative CRP-values in the robotic-group peaked one and two days later, respectively, and converged from POD 5 onward compared to the open-group. In the group with PIC, CRP-levels in the robotic-group were initially lower and started to differ significantly from POD 3 onward. In the open-group, increases were already noticed from POD 3 on. Procalcitonin levels did not differ. Best Receiver operating curve (ROC)-results were on POD 4, highest negative predictive values at POD 5 (RAMIE) and POD 4 (OE) with cut-off values of 70 mg/L and 88.3 mg/L, respectively. Conclusion: Post-operative CRP is a good negative predictor for PIC, after both RAMIE and OE. After RAMIE, CRP peaks later with a lower cut-off value.

The Role of ICG in Robot-Assisted Liver Resections

Introduction: Robotic-assisted liver surgery (RALS) with its known limitations is gaining more importance. The fluorescent dye, indocyanine green (ICG), is a way to overcome some of these limitations. It accumulates in or around hepatic masses. The integrated near-infrared cameras help to visualize this accumulation. We aimed to compare the influence of ICG staining on the surgical and oncological outcomes in patients undergoing RALS. Material and Methods: Patients who underwent RALS between 2014 and 2021 at the Department of General Surgery at the University Hospital Schleswig-Holstein, Campus Kiel, were included. In 2019, ICG-supported RALS was introduced. Results: Fifty-four patients were included, with twenty-eight patients (50.9%) receiving preoperative ICG. Hepatocellular carcinoma (32.1%) was the main entity resected, followed by the metastasis of colorectal cancers (17%) and focal nodular hyperplasia (15.1%). ICG staining worked for different tumor entities, but diffuse staining was noted in patients with liver cirrhosis. However, ICG-supported RALS lasted shorter (142.7 ± 61.8 min vs. 246.4 ± 98.6 min, p < 0.001), tumors resected in the ICG cohort were significantly smaller (27.1 ± 25.0 mm vs. 47.6 ± 35.2 mm, p = 0.021) and more R0 resections were achieved by ICG-supported RALS (96.3% vs. 80.8%, p = 0.075). Conclusions: ICG-supported RALS achieve surgically and oncologically safe results, while overcoming the limitations of RALS.

Today's Mistakes and Tomorrow's Wisdom in the Surgical Treatment of Barrett's Adenocarcinoma

Background

Barrett's esophagus is a premalignant condition caused by longstanding gastroesophageal reflux disease and may progress to low-grade dysplasia, high-grade dysplasia (HGD), and finally esophageal adenocarcinoma.

Summary

Barrett's adenocarcinoma can be treated either by endoscopic or surgical resection, depending on the clinical staging. Endoscopic resection is a safe and adequate treatment option for HGD, mucosal tumors, and low-risk submucosal tumors. Its role in the treatment of high-risk submucosal tumors and the role of organ-preserving sentinel node navigated surgery are still under investigation. Esophagectomy with neoadjuvant chemoradiation or perioperative chemotherapy is considered the standard of care for locally advanced Barrett's adenocarcinoma. Regarding operative technique, there is no proven superiority of one technique over another, although a minimally invasive transthoracic technique seems most commonly applied nowadays. In this review, state-of-the-art evidence and future expectations are presented regarding indications for resection, neoadjuvant or perioperative therapy, type of surgery, and postoperative follow-up for Barrett's adenocarcinoma.

Key Messages

In Barrett's adenocarcinoma, endoscopic resection is the standard treatment option for low-risk mucosal and submucosal tumors. For high-risk submucosal tumors, endoscopic submucosal dissection with close surveillance and sentinel node navigated surgery are currently being studied. For locally advanced cancer, a multimodal therapy including esophagectomy is the standard of care. Nowadays, in high-volume centers, a minimally invasive transthoracic esophagectomy with an intrathoracic anastomosis is the most common procedure for Barrett's adenocarcinoma.

Pancreatic Fistula and Biochemical Leak after Splenectomy: Incidence and Risk Factors-A Retrospective Single-Center Analysis

Purpose

Postoperative pancreatic fistula (POPF) is a complication discussed in the context of pancreatic surgery, but may also result from splenectomy; a relationship that has not been investigated extensively yet.

Methods

This retrospective single-center study aimed to analyze incidence of and risk factors for POPF after splenectomy. Patient characteristics included demographic data, surgical procedure, and intra- and postoperative complications. POPF was defined according to the International Study Group on Pancreatic Surgery as POPF of grade B and C or biochemical leak (BL).

Results

Over ten years, 247 patients were identified, of whom 163 underwent primary (spleen-associated pathologies) and 84 secondary (extrasplenic oncological or technical reasons) splenectomy. Thirty-six patients (14.6%) developed POPF of grade B/C or BL, of which 13 occurred after primary (7.9%) and 23 after secondary splenectomy (27.3%). Of these, 25 (69.4%) were BL, 7 (19.4%) POPF of grade B and 4 (11.1%) POPF of grade C. BL were treated conservatively while three patients with POPF of grade B required interventional procedures and 4 with POPF of grade C required surgery. POPF and BL was noted significantly more often after secondary splenectomy and longer procedures. Multivariate analysis confirmed secondary splenectomy and use of energy-based devices as independent risk factors for development of POPF/BL after splenectomy.

Conclusion

With an incidence of 4.5%, POPF is a relevant complication after splenectomy. The main risk factor identified was secondary splenectomy. Although POPF and BL can usually be treated conservatively, it should be emphasized when obtaining patients’ informed consent and treated at centers with experience in pancreatic surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02531-7.

Robotic-assisted minimally invasive Ivor Lewis esophagectomy within the prospective multicenter German da Vinci Xi registry trial

Abstract

Purpose

Robotic-assisted minimally invasive esophagectomy (RAMIE) has become one standard approach for the operative treatment of esophageal tumors at specialized centers. Here, we report the results of a prospective multicenter registry for standardized RAMIE.

Methods

The German da Vinci Xi registry trial included all consecutive patients who underwent RAMIE at five tertiary university centers between Oct 17, 2017, and Jun 5, 2020. RAMIE was performed according to a standard technique using an intrathoracic circular stapled esophagogastrostomy.

Results

A total of 220 patients were included. The median age was 64 years. Total minimally invasive RAMIE was accomplished in 85.9%; hybrid resection with robotic-assisted thoracic approach was accomplished in an additional 11.4%. A circular stapler size of ≥28 mm was used in 84%, and the median blood loss and operative time were 200 (IQR: 80–400) ml and 425 (IQR: 335–527) min, respectively. The rate of anastomotic leakage was 13.2% (n=29), whereas the two centers with >70 cases each had rates of 7.0% and 12.0%. Pneumonia occurred in 19.5% of patients, and the 90-day mortality was 3.6%. Cumulative sum analysis of the operative time indicated the end of the learning curve after 22 cases.

Conclusions

High-quality multicenter registry data confirm that RAMIE is a safe procedure and can be reproduced with acceptable leak rates in a multicenter setting. The learning curve is comparably low for experienced robotic surgeons.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02520-w.

Clinical significance of controlling nutritional status score (CONUT) in evaluating outcome of postoperative patients with gastric cancer

The stomach is the main digestive organ in humans. Patients with gastric cancer often develop digestive problems, which result in poor nutrition. Nutritional status is closely related to postoperative complications and quality of life (QoL) in patients with gastric cancer. The controlling nutritional status (CONUT) score is a novel tool to evaluate the nutritional status of patients. However, the relationship of the CONUT score with postoperative complications, QoL, and psychological status in patients with gastric cancer has not been investigated. The present follow-up study was conducted in 106 patients who underwent radical gastrectomy in our hospital between 2014 and 2019. The CONUT score, postoperative complications, psychological status, postoperative QoL scores, and overall survival (OS) of patients with gastric cancer were collected, and the relationship between them was analyzed. A significant correlation was observed between the CONUT score and postoperative complications of gastric cancer (P < 0.001), especially anastomotic leakage (P = 0.037). The multivariate regression analysis exhibited that the CONUT score (P = 0.002) is an independent risk factor for postoperative complications. The CONUT score was correlated with the state anxiety questionnaire (S-AI) for evaluating psychological status (P = 0.032). However, further regression analysis exhibited that the CONUT score was not an independent risk factor for psychological status. Additionally, the CONUT score was associated with postoperative QoL. The multivariate regression analysis exhibited that the CONUT score was an independent risk factor for the global QoL (P = 0.048). Moreover, the efficiency of CONUT score, prognostic nutrition index, and serum albumin in evaluating complications, psychological status, and QoL was compared, and CONUT score was found to outperform the other measures (Area Under Curve, AUC = 0.7368). Furthermore, patients with high CONUT scores exhibited shorter OS than patients with low CONUT scores (P = 0.005). Additionally, the postoperative complications (HR 0.43, 95% CI 0.21–0.92, P = 0.028), pathological stage (HR 2.26, 95% CI 1.26–4.06, P = 0.006), and global QoL (HR 15.24, 95% CI 3.22–72.06, P = 0.001) were associated with OS. The CONUT score can be used to assess the nutritional status of patients undergoing gastric cancer surgery and is associated with the incidence of postoperative complications and QoL.

A comparison between bronchial blockers and double-lumen tubes for patients undergoing lung resection: A propensity score-matched cohort study

Objective: The aim of this study is to compare the effect of bronchial blockers (BB) and double-lumen tubes (DLT) on patients' postoperative recovery after lung resection. Method: 4,636 patients undergoing lung resection and receiving either BB or DLT intubation were reviewed and matched using the propensity score matching method. The primary outcome was the surgical duration. The secondary outcomes included diagnostic results of postoperative chest X-ray, postoperative oxygenation index, incidence of hypercapnia, hypoxemia and sore throat, chest tube duration, incidence of ICU admission, length of hospital stay and incidence of the 30-day readmission. Results: After matching, 401 patients receiving BB were matched to 3,439 patients receiving DLT. There was no statistical difference on the surgical duration between the two groups (P>0.05). However, compared with the DLT group, patients in the BB group showed more infiltrate especially at the surgery side (14.96% versus 9.07%, P<0.001) based on the chest X-ray, together with higher incidence of ICU admission (5.23% versus 2.61%, P<0.05). Additionally, no statistical differences were found between the two groups about chest tube duration, oxygenation index, incidence of hypercapnia, hypoxemia and sore throat, duration of surgery, hospital stays and 30-day readmission (P>0.05). Conclusions: Compared with the DLT, patients receiving BB technique tend to have increased pulmonary infiltrate (especially the surgery side) and higher incidence of ICU admission at the early post-operative stage, which may have an influence on the patients' recovery.

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.

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.

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

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

Recent Advances in Laparoscopy

At the end of 2019, we received reports of abnormally high rates of severe pneumonia and mortality in a city named Wuhan in the province of Hubei in China [...].