Robotic assisted Ivor Lewis esophagectomy in the elderly patient

Esophagectomy in the Older Adult: A Systematic Review

Current management of esophageal carcinoma (EC) involves combining different modalities, offering the opportunity of personalized strategies. This is particularly enticing in the geriatric population, where tailoring treatment modalities remains key to achieve good outcomes in terms of both quality of life and survival. Primary outcomes of our review included (1) evidence on short-term outcomes following esophagectomy, and (2) evidence on long-term outcomes following esophagectomy. Secondary review questions compared outcomes of (1) neoadjuvant treatment versus upfront surgery for locally advanced esophageal carcinoma, (2) endoscopic submucosal dissection versus esophagectomy for early esophageal carcinoma, and (3) definitive radiation with or without chemotherapy versus surgery. Twenty-six articles were included in the review for the main review questions. Our systematic review underscores the need for comprehensive geriatric evaluations to guide decision-making. Despite concerns about perioperative risks, well-selected older patients can derive survival benefits from surgical intervention.

Comparison of Clinical Efficacy Between Da Vinci Robot-Assisted Ivor Lewis Esophagectomy and McKeown Esophagectomy for Middle and Lower Thoracic Esophageal Cancer: A Multicenter Propensity Score-Matched Study

BACKGROUND

We compared the perioperative efficacy and safety of da Vinci robot-assisted Ivor Lewis esophagectomy and McKeown esophagectomy for middle and lower thoracic esophageal cancer.

METHODS

A retrospective case-control study method was used. A total of 181 patients with esophageal cancer admitted to three medical centers in China from February 2018 to October 2022 were collected and divided into two groups according to surgical method: da Vinci robot-assisted thoracic surgery (RATS) Ivor Lewis esophagectomy (Ivor Lewis group) and RATS McKeown esophagectomy (McKeown group), respectively. Propensity score matching (PSM) analysis was used to reduce selection bias caused by confounding factors. The perioperative indicators of the two groups were compared and analyzed.

RESULTS

There was a statistically significant difference in age and tumor location between the Ivor Lewis group and the McKeown group. After PSM, the above factors were no longer statistically significant. There were 80 patients in each group after PSM. In terms of operative time (P = 0.005), anastomotic leakage (P = 0.029), and pulmonary infection (P = 0.035), the Ivor Lewis group has significant advantages; in terms of the number of lymph nodes dissected around the recurrent laryngeal nerve (P = 0.010), the McKeown group has significant advantages.

CONCLUSION

Both RATS Ivor Lewis esophagectomy and McKeown esophagectomy are safe and effective for treatment of middle and lower thoracic esophageal cancer. Ivor Lewis has advantages in operative time, anastomotic leakage, and pulmonary infection, while McKeown has advantage in lymph node dissection around the recurrent laryngeal nerve.

Suggested robotic-assisted thoracic surgery training curriculum

Robotic-assisted surgery, a technological advancement in the field of surgery, has become increasingly popular among surgeons of many specialties over time. Robotic-assisted thoracic surgery (RATS) is comparable to video-assisted thoracic surgery (VATS) in terms of patient care outcomes; however, the perception of increased operative time and a lack of cost-effectiveness have led to controversy regarding its alleged benefits. Nevertheless, robotic surgery is one of the preferred options for minimally invasive surgery by some thoracic surgeon over VATS, due to its ability to provide 3-D vision, precise wrist movements, enhanced magnification, and instrument stability and articulation. Notably, trainees in the field of thoracic surgery experience difficulty gaining knowledge and learning skills associated with RATS due to its complexity, limited access to robotic instruments, the lack of a standardized curriculum for trainees, and lack of mentorship or proctorship, thus leading to a steeper learning curve compared to laparoscopic or VATS procedures that are cost-friendly, easy to learn, and feasible to practice. Nevertheless, focusing on RATS training for thoracic surgeons will keep them familiar with robotic techniques, including the pre-operative setup and intra-operative process, which will ultimately decrease operative times. In this paper, we will review the literature, express and discuss the most viable training curriculum from authors' point of view to help achieve this goal.

Outcomes of curative esophageal cancer surgery in elderly: A meta-analysis

BACKGROUND

An increasing number of older patients is undergoing curative, surgical treatment of esophageal cancer. Previous meta-analyses have shown that older patients suffered from more postoperative morbidity and mortality compared to younger patients, which may lead to patient selection based on age. However, only studies including patients that underwent open esophagectomy were included. Therefore, it remains unknown whether there is an association between age and outcome in patients undergoing minimally invasive esophagectomy.

AIM

To perform a systematic review on age and postoperative outcome in esophageal cancer patients undergoing esophagectomy.

METHODS

Studies comparing older with younger patients with primary esophageal cancer undergoing curative esophagectomy were included. Meta-analysis of studies using a 75-year age threshold are presented in the manuscript, studies using other age thresholds in the Supplementary material. MEDLINE, Embase and the Cochrane Library were searched for articles published between 1995 and 2020. Risk of bias was assessed with the Newcastle-Ottawa Scale. Primary outcomes were anastomotic leak, pulmonary and cardiac complications, delirium, 30- and 90-d, and in-hospital mortality. Secondary outcomes included pneumonia and 5-year overall survival.

RESULTS

Seven studies (4847 patients) using an age threshold of 75 years were included for meta-analysis with 755 older and 4092 younger patients. Older patients (9.05%) had higher rates of 90-d mortality compared with younger patients (3.92%), (confidence interval = 1.10-5.56). In addition, older patients (9.45%) had higher rates of in-hospital mortality compared with younger patients (3.68%), (confidence interval = 1.01-5.91). In the subgroup of 2 studies with minimally invasive esophagectomy, older and younger patients had comparable 30-d, 90-d and in-hospital mortality rates.

CONCLUSION

Older patients undergoing curative esophagectomy for esophageal cancer have a higher postoperative mortality risk. Minimally invasive esophagectomy may be important for minimizing mortality in older patients.

Oncologic Resection in Laparoscopic Versus Robotic Transhiatal Esophagectomy

Background and Objectives:

As the use of robotic surgery continues to increase, little is known about robotic oncologic outcomes compared with traditional methods in esophagectomy. The aim of this study was to examine the perioperative oncologic outcomes of patients undergoing laparoscopic versus robot-assisted transhiatal esophagectomy (THE).

Methods:

Thirty-six consecutive patients who underwent laparoscopic and robot-assisted THE for malignant disease over a 3-year period were identified in a retrospective database. Eighteen patients underwent robotic-assisted THE with cervical anastomosis, and 18 patients underwent laparoscopic THE. All procedures were performed by a single foregut and thoracic surgeon.

Results:

Patient demographics were similar between the 2 groups with no significant differences. Lymph node yields for both laparoscopic and robot-assisted THE were similar at 13.9 and 14.3, respectively (P = .90). Ninety-four percent of each group underwent R0 margins, but only 1 patient from each modality had microscopic positive margins. All of the robot-assisted patients underwent neoadjuvant chemoradiation, whereas 83.3% underwent neoadjuvant therapy in the laparoscopy group (P = .23). Clinical and pathologic stagings were similar in each group. There was 1 death after laparoscopic surgery in a cirrhotic patient and no mortalities among the robot-assisted THE patients (P = .99). One patient from each group experienced an anastomotic leak, but neither patient required further intervention.

Conclusions:

Laparoscopic and robot-assisted THEs yield similar perioperative oncologic results including lymph node yield and margin status. In the transition from laparoscopic surgery, robotic surgery should be considered oncologically noninferior compared with laparoscopy.

The Influence of Age on Complications and Overall Survival After Ivor Lewis Totally Minimally Invasive Esophagectomy

BACKGROUND

The number of elderly patients suffering from esophageal cancer is increasing, due to an increasing incidence of esophageal cancer and increasing life expectancy. However, the effect of age on morbidity, mortality, and survival after Ivor Lewis total minimally invasive esophagectomy (TMIE) is not well known.

METHODS

A prospectively documented database from December 2010 to June 2017 was analyzed, including all patients who underwent Ivor Lewis TMIE for esophageal cancer in three Dutch high-volume esophageal cancer centers. Patients younger than 75 years (younger group) were compared to patients aged 75 years or older (elderly group). Baseline patient characteristics and perioperative data were included. Surgical complications were graded using the Clavien-Dindo scale. The primary outcome was postoperative complications Clavien-Dindo ≥ 3. Secondary outcome parameters were postoperative complications, in-hospital mortality, 30- and 90-day mortality and survival.

RESULTS

Four hundred and forty-six patients were included, 357 in the younger and 89 in the elderly group. No significant differences were recorded regarding baseline patient characteristics. There was no significant difference in complications graded Clavien-Dindo ≥ 3 and overall complications, short-term mortality, and survival. Delirium occurred in 27.0% in the elderly and 11.8% in the younger group (p < 0.001). After correction for baseline comorbidity this difference remained significant (p = 0.001). Median hospital length of stay was 13 days in the elderly and 11 days in the younger group (p = 0.010).

CONCLUSIONS

Ivor Lewis TMIE can be safely performed in selected elderly patients without increasing postoperative morbidity and mortality.

Upper Gastrointestinal Surgery: Robotic Surgery versus Laparoscopic Procedures for Esophageal Malignancy

Background

The evolution of minimally invasive surgery (MIS) also extends to the field of esophageal surgery and has brought forth the development of several approaches of minimally invasive esophagectomy (MIE). Hybrid and total minimally invasive operative techniques have proven beneficial compared to open surgery and are currently evaluated against robotic-assisted minimally invasive esophagectomy (RAMIE). We aim to review the current literature regarding the position of MIE versus RAMIE.

Methods

A systematic review of the relevant literature on minimally invasive esophageal surgery for cancer is presented. A PubMed search was carried out for the period of 1992-2018 with the following search terms: 'esophageal cancer', 'minimally invasive surgery', 'resection', 'transhiatal', 'transthoracic', 'MIE', 'hybrid', 'robotic resection', 'RAMIE', 'RATE'.

Results

Hybrid and total minimally invasive operative techniques have proven beneficial, especially with regard to pulmonary complications, compared to open surgery. Oncologic outcomes appear equivalent between open and minimally invasive techniques. Currently, the position of RAMIE is being evaluated against other minimally invasive techniques.

Conclusion

All minimally invasive techniques confer the expected reduction in perioperative morbidity compared to open surgery. However, MIS is still evolving with regard to specific technical challenges, especially anastomotic techniques.

Robotic-assisted Ivor Lewis esophagectomy: technique and early outcomes

Esophagectomy is pivotal for the long-term survival in patients with early stage and advanced esophageal cancer, and improved perioperative care and advanced surgical techniques have contributed to reduced postoperative morbidity. However, despite these advances, esophagectomy continues to be associated with significant morbidity and mortality. Minimally invasive esophageal surgery (MIE) has been increasingly used in patients undergoing surgery for esophageal cancer. Potential advantages of MIE include the decreased postoperative pain; lower postoperative wound infection, decreased pulmonary complications, and decreased length of hospitalization. Robotic esophageal surgery has the ability to overcome some of the limitations of laparoscopic and thoracoscopic approaches to esophagectomy while maintaining the benefits of the minimally invasive approach. In this article, we will review the clinical efficacy and outcomes associated with robotic-assisted Ivor Lewis esophagectomy (RAIL).

Robotic surgery for esophageal cancer: Merits and demerits

Since the introduction of robotic systems in esophageal surgery in 2000, the number of robotic esophagectomies has been gradually increasing worldwide, although robot‐assisted surgery is not yet regarded as standard treatment for esophageal cancer, because of its high cost and the paucity of high‐level evidence. In 2016, more than 1800 cases were operated with robot assistance. Early results with small series demonstrated feasibility and safety in both robotic transhiatal (THE) and transthoracic esophagectomies (TTE). Some studies report that the learning curve is approximately 20 cases. Following the initial series, operative results of robotic TTE have shown a tendency to improve, and oncological long‐term results are reported to be effective and acceptable: R0 resection approaches 95%, and locoregional recurrence is rare. Several recent studies have demonstrated advantages of robotic esophagectomy in lymphadenectomy compared with the thoracoscopic approach. Such technical innovations as three‐dimensional view, articulated instruments with seven degrees of movement, tremor filter etc. have the potential to outperform any conventional procedures. With the aim of preventing postoperative pulmonary complications without diminishing lymphadenectomy performance, a nontransthoracic radical esophagectomy procedure combining a video‐assisted cervical approach for the upper mediastinum and a robot‐assisted transhiatal approach for the middle and lower mediastinum, transmediastinal esophagectomy, was developed; its short‐term outcomes are promising.

Thus, the merits or demerits of robotic surgery in this field remain quite difficult to assess. However, in the near future, the merits will definitely outweigh the demerits because the esophagus is an ideal organ for a robotic approach.