Comparative outcomes of robot-assisted minimally invasive versus open esophagectomy in patients with esophageal squamous cell carcinoma: a propensity score-weighted analysis

Abstract

SUMMARY Robots are increasingly used in minimally invasive surgery. We evaluated the clinical benefits of robot-assisted minimally invasive esophagectomy (RAMIE) in comparison with the conventional open esophageal surgery. From 2012 to 2016, 371 patients with esophageal squamous cell carcinoma underwent an Ivor Lewis or McKeown procedure at our institution. Of these, 130 patients underwent laparoscopic gastric conduit formation followed by RAMIE, whereas 241 patients underwent conventional esophageal surgery, including laparotomy and open esophagectomy (OE). We compared the short- and long-term clinical outcomes of these patients using the propensity score-based inverse probability of treatment weighting technique (IPTW). Among the early outcomes, the OE group showed a higher incidence of pneumonia (P = 0.035) and a higher requirement for vasopressors (P = 0.001). Regarding the long-term outcomes, all-cause mortality was significantly higher (P = 0.001) and disease-free survival was lower (P = 0.006) in the OE group. Wound-related problems also occurred more frequently in the OE group (P = 0.020) during the long-term follow-up. There was no statistical intergroup difference in the recurrence rates (P = 0.191). The Cox proportional-hazard analysis demonstrated that wound problems (HR 0.16, 95% CI 0.02–0.57; P = 0.017), pneumonia (HR 0.23, 95% CI 0.06–0.68; P = 0.019), and use of vasopressors (HR 0.14, 95% CI 0.08–0.25; P = 0.001) were independent predictors of mortality. RAMIE could be a better surgical option for selected patients with esophageal squamous cell carcinoma.

Early Respiratory Impairment and Pneumonia after Hybrid Laparoscopically Assisted Esophagectomy—A Comparison with the Open Approach

“…If minimally invasive thoracoscopy is superior to thoracotomy in the context of esophagectomy, is still a matter of debate [23,25,27,29,30]. However, ample evidence including the prospectively conducted randomized MIRO trial reported considerably higher incidences of major pulmonary complications after open esophagectomy (OE) compared to hybrid minimally invasive laparoscopically assisted esophagectomy (LAE) [21,22,24,[29][30][31][32]. This might be due to reduced abdominal pain and trauma in comparison to open surgery [15,[17][18][19][20]22,31,[33][34][35].…”

“…However, ample evidence including the prospectively conducted randomized MIRO trial reported considerably higher incidences of major pulmonary complications after open esophagectomy (OE) compared to hybrid minimally invasive laparoscopically assisted esophagectomy (LAE) [21,22,24,[29][30][31][32]. This might be due to reduced abdominal pain and trauma in comparison to open surgery [15,[17][18][19][20]22,31,[33][34][35]. As the trauma-associated release of danger-associated molecular patterns (DAMPs) is expected to directly cause pulmonary barrier dysfunction [17,19,20], a better early postoperative lung function should be expected in patients undergoing minimally invasive surgery.…”

“…We hypothesized that partial or complete vagal denervation of the lung, bronchi, and pulmonary vasculature, that is typical for oncologic esophagectomies, causes a dysbalance of the autonomic nervous system innervating pulmonary structures and eventually impairs gas exchange [5]. Another possible explanation is the abdominal part of the esophagectomy that is associated with additional surgical trauma and more pain [15,[17][18][19][20]22,31,[33][34][35].…”

“…In contrast to the above mentioned studies from other authors [21,22,24,[29][30][31][32], we included the highly sensitive P/FR that enables us to investigate pulmonary impairment in the early postoperative phase [5]. We critically scrutinize the common hypothesis that the minimally invasive LAE causes less pulmonary damage compared to OE because of reduced intraoperative trauma [17][18][19][20]35].…”

Robotische Ösophaguresektion (RAMIE) – Setup, Port Placement, strukturierte OP-Schritte

“…Lewis). Neben der im Folgenden vorgestellten Technik sind von anderen Arbeitsgruppen unterschiedliche technische Vorgehensweisen publiziert worden [5,6]. Aus unserer Sicht kann die roboterassistierte Operation, insbesondere beim thorakalen Teil mit Anastomose und Lymphadenektomie, die technischen Limitationen der konventionellen thorakoskopischen Technik überwinden.…”