Robotic Versus Conventional Minimally Invasive Esophagectomy for Esophageal Cancer

Abstract

Objectives: To give a comprehensive review of the literature comparing perioperative outcomes and long-term survival with robotic-assisted minimally invasive esophagectomy (RAMIE) versus minimally invasive esophagectomy (MIE) for esophageal cancer. Background: Curative minimally invasive surgical treatment for esophageal cancer includes RAMIE and conventional MIE. It remains controversial whether RAMIE is comparable to MIE. Methods: This review was registered at the International Prospective Register of Systematic Reviews (CRD42021260963). A systematic search of databases was conducted. Perioperative outcomes and long-term survival were analyzed and subgroup analysis was conducted. Cumulative meta-analysis was performed to track therapeutic effectiveness. Results: Eighteen studies were included and a total of 2932 patients (92.88% squamous cell carcinoma, 29.83% neoadjuvant therapy, and 38.93% stage III-IV), 1418 underwent RAMIE and 1514 underwent MIE, were analyzed. The number of total lymph nodes (LNs) [23.35 (95% CI: 21.41–25.29) vs 21.98 (95% CI: 20.31–23.65); mean difference (MD) = 1.18; 95% CI: 0.06–2.30; P=0.04], abdominal LNs [9.05 (95% CI: 8.16–9.94) vs 7.75 (95% CI: 6.62–8.88); MD = 1.04; 95% CI: 0.19–1.89; P=0.02] and LNs along the left recurrent laryngeal nerve [1.74 (95% CI: 1.04–2.43) vs 1.34 (95% CI: 0.32–2.35); MD = 0.22; 95% CI: 0.09–0.35; P <0.001] were significantly higher in the RAMIE group. RAMIE is associated with a lower incidence of pneumonia [9.61% (95% CI: 7.38%–11.84%) vs 14.74% (95% CI: 11.62%–18.15%); odds ratio = 0.73; 95% CI: 0.58-0.93; P=0.01]. Meanwhile, other perioperative outcomes, such as operative time, blood loss, length of hospital stay, 30/90-day mortality, and R0 resection, showed no significant difference between the two groups. Regarding long-term survival, the 3-year overall survival was similar in the two groups, whereas patients undergoing RAMIE had a higher rate of 3-year disease-free survival compared with the MIE group [77.98% (95% CI: 72.77%–82.43%) vs 70.65% (95% CI: 63.87%–77.00%); odds ratio = 1.42; 95% CI: 1.11–1.83; P=0.006]. A cumulative meta-analysis conducted for each outcome demonstrated relatively stable effects in the two groups. Analyses of each subgroup showed similar overall outcomes. Conclusions: RAMIE is a safe and feasible alternative to MIE in the treatment of resectable esophageal cancer with comparable perioperative outcomes and seems to indicate a possible superiority in LNs dissection in the abdominal cavity, and LNs dissected along the left recurrent laryngeal nerve and 3-year disease-free survival in particular in esophageal squamous cell carcinoma. Further randomized studies are needed to better evaluate the long-term benefits of RAMIE compared with MIE.

Online tools to predict individualised survival for primary oesophageal cancer patients with and without pathological complete response after neoadjuvant therapy followed by oesophagectomy: development and external validation of two independent nomograms

“…Significant protective factors included a later year of diagnosis and higher number of resected LNs. Although not statistically significant, the histology type,43 pretreatment cM stage47 and surgical approach44–46 were included in the final model owing to their clinical relevance. The proportionality of hazards was confirmed by the Schoenfeld residual test (p=0.079).…”

“…Previous randomised controlled studies, including the MIRO trial44 and ROBOT trial,45 have demonstrated that both hybrid minimally invasive oesophagectomy and robotic oesophagectomy had lower complication rates than those of open surgery. Recently, an updated meta-analysis conducted by our team comparing robot-assisted versus conventional minimally invasive oesophagectomy found that robotic surgery resulted in a higher 3-year disease-free survival rate 46. Considering these results, the surgical approach was included in our predictive models.…”

“…Recently, an updated meta-analysis conducted by our team comparing robot-assisted versus conventional minimally invasive oesophagectomy found that robotic surgery resulted in a higher 3-year disease-free survival rate. 46 Considering these results, the surgical approach was included in our predictive models. Multivariable Cox regression analyses showed that robotic surgery tended to prolong OS compared with open surgery for both non-pCR (HR, 0.73; 95% CI 0.60 to 0.88; p = 0.001) and pCR (HR, 0.78; 95% CI 0.51 to 1.19; p = 0.250) patients, although the protective effect was not statistically significant in the latter population.…”

Mid-term outcomes of robotic-assisted versus video-assisted invasive minimally esophagectomy for esophageal cancer: A retrospective propensity-matched analysis of 842 patients

“…The inclusion criteria: (1) esophageal squamous cell carcinoma was con rmed by preoperative gastroscopy; (2) no distant metastasis was found in preoperative examination and postoperative pathology. Exclusion criteria: (1) previous history of cancer or malignant tumors in other parts of the body; (2) patients with severe lung diseases; (3) esophagectomy with mediastinoscopy; (4) thoracotomy or laparotomy for esophageal cancer resection; (5) Incomplete data. The study recruited 842 patients: 148 in the robotic group and 694 in the laparoscopic group.…”

“…[4] With the continuous development of Da Vinci robot system, robot-assisted minimally invasive esophagectomy (RAMIE) has become another option for the minimally invasive treatment of esophageal cancer. [5] In recent years, studies on the short-term and longterm e cacy of RAMIE in the treatment of esophageal cancer have gradually attracted attention.However, as one of the most RAMIE centers in southern China, it is still important to compare the midterm survival outcomes between RAMIE and VAMIE. The aim of this study is to compare the safety, effectiveness, and mid-term survival rates of RAMIE and VAMIE using propensity score matching (PSM) analysis.…”