Operative and survival outcomes in a series of 100 consecutive cases of robot-assisted transhiatal esophagectomies

Abstract

Robotic-assisted transhiatal esophagectomy (RATE) is a technically complex procedure with potential for improved postoperative outcomes. In this report, we describe our experience with RATE in a large case series. A retrospective review was conducted to collect clinical, outcomes, and survival data for 100 consecutive patients with esophageal cancer (n = 98) and benign (n = 2) conditions undergoing RATE between March 2007 and December 2014. Progression-free (PFS) and overall (OS) survival were estimated using the Kaplan-Meier curves with comparisons by log-rank tests. Median operative time and estimated blood loss were 264 minutes and 75 mL, respectively. Median intensive care unit stay was 1 day and median length of hospital stay was 8 days. Postoperative complications commonly observed were nonmalignant pleural effusion (38%) and recurrent laryngeal nerve injury (33%); 30 day mortality rate was 2%. Median number of lymph nodes removed during RATE was 17 and R0 resection was achieved in 97.8% patients. At the end of the median follow-up period of 27.7 months, median PFS was 41 months and median OS was 54 months. 1-year and 3-year PFS rates were 82% (95% CI, 75%-89%) and 53% (95% CI, 42%-62%), respectively, and OS rates were 95% (95% CI, 91%-99%) and 57% (95% CI, 46%-67%). In our experience, RATE is an effective and safe oncologic surgical procedure in a carefully selected group of patients with acceptable operative time, minimal blood loss, standard postoperative morbidity and adequate PFS and OS profiles.

THE Big Deal: An Institution's Experience with Robotic Transhiatal Esophagectomy

“…Our conversion rate of less than one in 10 is similar to that of other studies. 8,10 Our conversions were due to failures to progress, mostly because of severe inflammatory and adhesive processes. Patients who completed the operations robotically had less EBL and shorter lengths of stay when compared with patients whose esophagectomies were converted to "open."…”

“…Similar issues with pulmonary complications after esophagectomy are found within both the transhiatal literature and transthoracic literature. 8,10,[13][14][15] Nearly one patient in 10 had an SSI, all of which were quite trivial and involved the incisions for the robotic trocars; some appeared after discharge and all resolved with antibiotics. This rate of SSIs seems high for our practice.…”

“…There have been several institutional experiences of robotic-assisted THE reported in the literature. [8][9][10][11][12] Our collection of 45 patients is the largest to date for robotic THE. In comparison, e.g., our length of stay of nearly one week is shorter, nevertheless, there are multiple areas for improvement.…”

“…Whereas there is a plethora of articles on the thorascopic approach, there are only a handful of experiential reports describing the transhiatal approach. [8][9][10] The first robotic-assisted transhiatal esophagectomy (THE) case report was written by Horgan et al 11 in 2003, in which a T1M0N0 distal esophageal cancer was resected successfully. In 2007, Galvani et al 12 followed with a similar report of 18 patients.…”

International consensus statement on robot-assisted minimally invasive esophagectomy (RAMIE)

“…THE, which is thought to preserve pulmonary function and potentially enhance postoperative recovery (25,26), is frequently applied for the treatment of adenocarcinoma of the lower esophagus or early squamous cell esophageal cancer (27,28). THE was the first robotic-assisted esophagectomy performed, mainly because robotic surgery at the time had only been carried out on the abdomen, and so it started with this hybrid approach (29). At present, robotic dissection can reach freely up to the lower pulmonary vein through the hiatus, but cannot easily reach the carina.…”