A refined procedure for esophageal resection using a full minimally invasive approach

Abstract

Objective Newer minimally invasive approaches to esophagectomy have brought substantial benefits to esophageal-cancer patients and continue to improve. We report here our experience with a streamlined procedure as part of a comprehensive perioperative-care program that provides additional advances in the continued evolution of this procedure. Methods All patients with primary esophageal cancer referred for resection to the Oakland Medical Center of the Kaiser-Permanente Northern California health plan who underwent this approach between January 2013 and August 2018 were included. Operative and clinical outcome variables were extracted from the electronic medical record, operating-room files, and manual chart review. Results 142 patients underwent the new procedure and care program; 121 (85.2%) were men with mean age of 64.5 years. 127 (89.4%) were adenocarcinoma; 117 (82.4%) were clinical stage III or IVA. 115 (81.0%) required no jejunostomy. Median hospital length-of-stay was 3 days and 8 (5.6%) patients required admission to the intensive care unit. Postoperative complications occurred in 22 (15.5%) patients within 30 days of the procedure. There were no inpatient deaths; one patient (0.7%) died within 30 days following discharge and three additional deaths (2.1%) occurred through 90 days of follow-up. Conclusions This approach resulted in excellent clinical outcomes, including short hospital stays with limited need for the intensive care unit, few perioperative complications, and relatively few patients requiring feeding tubes on discharge. This comprehensive approach to esophagectomy is feasible and provides another clinically meaningful advance in the progress of minimally invasive esophagectomy. Further development and dissemination of this method is warranted.

Outcomes of Minimally Invasive and Robot-Assisted Esophagectomy for Esophageal Cancer

“…Over the last decade, reported case times for MIE (237 to 443 min) and RAMIE (204 to 490 min) are wide ranging while reported times for open esophagectomy (295 to 339 min) are much less variable [ 9 , 12 , 15 , 16 , 18 , 19 , 21 , 29 , 31 , 32 ]. These findings are likely related to the relatively new nature of MIE, and especially RAMIE, when compared to open esophagectomy.…”

“…Reports of estimated blood loss in MIE and RAMIE range from 100 to 350 mL and 120 to 331 mL, respectively, while those of estimated blood loss during open esophagectomy range from 200 to 500 mL [ 9 , 15 , 16 , 18 , 19 , 21 , 29 , 31 , 32 ].…”

“…A 2021 meta-analysis of 60 studies ranging from 2008 through to 2020 (predominantly retrospective) found higher rates of R0 resection among RAMIE compared to MIE (OR 2.84, 95% CI 1.53–5.26), however, this contrasts with results of the more recent randomized controlled trial by Yang et al that found no difference between RAMIE and MIE in terms of this metric (95.0% vs. 92.1%, respectively; p = 0.26) [ 27 , 32 ]. Reports of R0 resections for MIE, RAMIE, and open esophagectomy range from 90.1% to 97.5%, 92% to 96.9%, and 83.9% to 97.2%, respectively [ 9 , 18 , 19 , 21 , 31 , 32 , 33 ].…”

“…Reported ranges over the last decade of lymph node yield among MIE, RAMIE, and open esophagectomy are 12 to 23 nodes, 19 to 29 nodes, and 21 to 25 nodes, respectively [ 9 , 12 , 15 , 16 , 18 , 19 , 21 , 29 , 31 , 32 ]. It is not entirely clear from this data whether there is a clear benefit of one approach over another in terms of lymph node yield.…”

“…The ranges of reported anastomotic leak rates among MIE, RAMIE, and open esophagectomy among the reviewed studies were 2.1% to 13.2%, 3.0% to 24.1%, and 7.0% to 25.3%, respectively [ 9 , 12 , 15 , 18 , 19 , 21 , 29 , 30 , 31 , 32 ]. Interestingly, the 24.1% leak rate among RAMIE was found in the ROBOT randomized controlled trial which found a similarly high leak rate among open esophagectomy as well (20.0%) [ 15 ].…”