Attaining Proficiency in Robotic-Assisted Minimally Invasive Esophagectomy While Maximizing Safety during Procedure Development

Abstract

Objective-Robotic-assisted minimally invasive esophagectomy (RAMIE) is an emerging, complex operation with limited reports detailing morbidity, mortality, and requirements for attaining proficiency. Our objective was to develop a standardized RAMIE technique, evaluate procedure safety, and assess outcomes using a dedicated operative team and two surgeon approach. Methods-We conducted a study of sequential patients undergoing RAMIE from January 25, 2011, May 5, 2014. Intermedian demographics and perioperative data were compared between sequential halves of the experience using Wilcoxon rank sum test and Fischer's exact test. Median operative time was tracked over successive 15-patient cohorts. Results-100 of 313 esophageal resections performed at our institution underwent RAMIE during the study period. A dedicated team including two attending surgeons, and uniform anesthesia and OR staff was established. Patient demographics and outcomes are summarized in Table 1. There were no significant differences in age, gender, histology, stage, induction therapy, or risk class between the two halves of the study. Estimated blood loss, conversions, operative times, and overall complications significantly decreased. The median resected lymph nodes increased, but was not statistically significant. Median operative time decreased to approximately 370 minutes between the 30 th and the 45 th cases (Figure 1). There were no emergent intraoperative complications and the anastomotic leak rate was 6% (6/100). 30-day mortality was 0% (0/100) and 90-day mortality was 1% (1/100). Conclusions-Excellent perioperative and short-term patient outcomes with minimal mortality can be achieved using a standardized RAMIE procedure and dedicated team approach.

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

“…15 The percentage of anastomotic was comparable to other studies describing a robot-assisted Ivor Lewis procedure. [22][23][24] These data might suggest that an (circularly stapled) Ivor Lewis anastomosis might reduce anastomotic insufficiency in patients with esophageal cancer compared to a McKeown procedure, which is in concordance with recent literature. 25 A randomized controlled trial is currently being performed to answer the question whether a McKeown or Ivor Lewis procedure should be preferred in patients undergoing MIE.…”

“…Short-term oncologic results and short-term survival data were comparable to studies describing (minimally in) esophagectomy. 5,8,10,22 With proven superiority of MIE over OTE, the question remains, whether the technical advantages of RAMIE contribute to better results compared to conventional MIE. In Asian studies, where RAMIE was compared to MIE, a higher mean lymph node yield along the recurrent laryngeal nerve was observed in favor of RAMIE.…”

The Learning Curve for Robotic McKeown Esophagectomy in Patients With Esophageal Cancer

“…Intraoperative and Postoperative Variables decreased after 29 cases[19]. Sarkaria and colleagues[20] conducted a learning curve analysis of 100 robot-assisted MIEs and noted that the median operative time decreased to approximately 370 minutes between the 30th and the 45th cases; however, both Ivor Lewis MIEs and McKeown MIEs were enrolled in the study by Sarkaria and colleagues. Because creation of an intrathoracic esophagogastrostomy is more complex than construction of an anastomosis in the neck, we had to analyze the learning curve of Ivor Lewis MIE and McKeown MIE, respectively.…”

Patient reported outcomes (PROs) after minimally invasive and open esophagectomy

“…While high quality data for robotic approaches compared to open remains less robust in comparison with minimally invasive approaches, data is maturing in favor of the robotic assisted approaches. However, it is important to note that robotic assisted techniques and approaches vary in the literature, with the only completely robotic approach published by Sarkaria and colleagues (15)(16)(17).…”