Outcomes of 350 Robotic-assisted Esophagectomies at a High-volume Cancer Center

Abstract

Objective:To evaluate perioperative and oncologic outcomes in our RAMIE cohort and compare outcomes with contemporary OE controls.Summary of Background Data:RAMIE has emerged as an alternative to traditional open or laparoscopic approaches. Described in all esophagectomy techniques, rapid adoption has been attributed to both enhanced visualization and technical dexterity.Methods:We retrospectively reviewed patients who underwent RAMIE for malignancy. Patient characteristics, perioperative outcomes, and survival were evaluated. For perioperative and oncologic outcome comparison, contemporary OE controls were propensity-score matched from NSQIP and NCDB databases.Results:We identified 350 patients who underwent RAMIE between 2010 and 2019. Median body mass index was 27.4, 32% demonstrated a Charlson Comorbidity Index >4. Nodal disease was identified in 50% of patients and 74% received neoadjuvant chemoradiotherapy. Mean operative time and blood loss were 425 minutes and 232 mL, respectively. Anastomotic leak occurred in 16% of patients, 2% required reoperation. Median LOS was 9 days, and 30-day mortality was 3%. A median of 21 nodes were dissected with 96% achieving an R0 resection. Median survival was 67.4 months. 222 RAMIE were matched 1:1 to the NSQIP OE control. RAMIE demonstrated decreased LOS (9 vs 10 days, P = 0.010) and reoperative rates (2.3 vs 12.2%, P = 0.001), longer operative time (427 vs 311 minutes, P = 0.001), and increased rate of pulmonary embolism (5.4% vs 0.9%, P = 0.007) in comparison to NSQIP cohort. There was no difference in leak rate or mortality. Three hundred forty-three RAMIE were matched to OE cohort from NCDB with no difference in median overall survival (63 vs 53 months; P = 0.130).Conclusion:In this largest reported institutional series, we demonstrate that RAMIE can be performed safely with excellent oncologic outcomes and decreased hospital stay when compared to the open approach.

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

“…A total of 507 studies were excluded for the following reasons: 44 were written in a language other than English, 10 were case reports/case series, 97 were reviews, 46 were non-comparative studies, 293 were off-topic and 18 did not provide any usable data. Thus, 35 studies were included in the final analysis, out of which 20 compared robotic vs. laparoscopic surgery, 11 compared robotic vs. open esophagectomy and 4 reported on a three-arms comparison (robotic vs. laparoscopic vs. open) [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 ]. From the latter [ 54 ], it was possible to extract only data about the comparison between robotic and laparoscopic esophagectomy.…”

“…Operative time was reported by 9 Authors [11,35,37,38,41,45,46,61,63] were performed with a fully robotic approach, except for the study by Rolff et al [45], in which an hybrid procedure (robotic approach to the abdomen and open approach to the thorax) was used. Two articles reported on Ivor-Lewis procedure [37,39], one on McKeown esophagectomy [61] while ten did not provide relevant data to allow subgroup analysis [11,35,41,[44][45][46]52,[62][63][64].…”

“…Operative time was reported by 9 Authors [11,35,37,38,41,45,46,61,63] Postoperative complications are shown in Figure 8. Anastomotic leakage was analysed by 8 Authors [11,35,39,41,44,46,61,63] on 2188 procedures (823 robotic and 1365 open), with no statistical differences between the two approaches (OR = 0.953, p = 0.799, 95%CI 0.655; 1.385) and no significant heterogeneity among the studies (I 2 = 0%, p = 0.556). Postoperative bleeding was reported by 4 Authors [11,46,61,63] on 818 procedures (339 robotic and 479 open), demonstrating no significant differences between the two groups (RD = −0.007, p = 0.372, 95%CI −0.022; 0.008) and no significant heterogeneity among the studies (I 2 = 0%, p = 0.439).…”

“…To perform this subgroup analysis only the study by Rolff et al [45] and Weksler et al [52] were excluded. Thus, the subgroup analysis included eleven studies [11,35,37,38,41,44,46,[61][62][63][64] About postoperative complications, only data about mortality could be extracted, without a significant difference between the two approaches (OR = 0.855, p = 0.668, 95%CI 0.418; 1.748).…”

“…All were prospective ( n = 5) or retrospective studies ( n = 18) [ 20 , 21 , 22 , 23 , 29 , 32 , 33 , 37 , 40 , 42 , 43 , 44 , 45 , 46 , 48 , 51 , 53 ], reporting on 11,779 patients, of whom 3832 underwent robotic esophagectomy and 7947 laparoscopic esophagectomy. The characteristics of the included studies are summarized in Table 1 .…”