Long-term outcomes of robotic-assisted versus thoraco-laparoscopic McKeown esophagectomy for esophageal cancer: a propensity score-matched study

Abstract

Summary The long-term outcomes of robotic-assisted McKeown esophagectomy (RAME) compared to thoraco-laparoscopic McKeown esophagectomy (TLME) for the patients with esophageal squamous cell carcinoma (ESCC) remain unclear. The aim of this study was to compare the number of dissected lymph nodes and long-term survival between RAME and TLME using a propensity score-matched (PSM) analysis. A total of 721 patients undergoing minimally invasive McKeown esophagectomy at our department from February 2015 to October 2019 were analyzed, including 310 patients in RAME group and 411 in TLME group. The exact numbers of lymph nodes including those among thoracic and abdominal categories as well as those along the recurrent laryngeal nerve (RLN) were all recorded. PSM analysis was applied to generate matched pairs for further comparison. All patients with R0 resection were followed with a strict follow-up period which range from 1 to 56 months. The effect of lymphadenectomy was compared between all patients in unmatched and matched groups. Long-term outcomes consisting of overall survival (OS), disease-free survival (DFS) and recurrence rate (including regional recurrence rate, systemic recurrence rate and mediastinal lymph nodes recurrence rate) were compared in R0 resection patients. Finally, 292 patients were identified for each cohort after PSM. RAME was found to yield significantly more left RLN lymph nodes (mean: 2.27 ± 0.90 vs. 2.09 ± 0.79; P = 0.011) and more thoracic lymph nodes (mean: 12.60 ± 4.22 vs. 11.83 ± 3.12, P = 0.012) compared with TLME after PSM analysis. There was no significant difference in the OS and DFS between the RAME and TLME group. Besides, total recurrences were recognized in 33 (11.7%) patients in the RAME group and 36 (12.9%) in the TLME group (P = 0.676). The mediastinal lymph nodes recurrence rate in the RAME group was tended to be lower than that in the TLME group (2.5% vs. 5.4%, P = 0.079). Therefore, RAME might be an alternative approach for the treatment of ESCC with more lymph nodes dissected and similar long-term survival outcomes compared to TLME.

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.…”

“…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. Record selection is illustrated in the PRISMA flowchart ( Figure 1 ).…”

“…Postoperative wound infection was analysed by 10 Authors [32,38,49,51,53,54,56,57,60,61] on 2189 procedures (1088 robotic and 1101 laparoscopic), with no significant differences between the two approaches (RD = −0.001, p = 0.885, 95%CI −0.010; 0.009) and no significant heterogeneity among the studies (I 2 = 7.881%, p = 0.370). Pneumonia was reported by 15 Authors [27,29,32,[38][39][40]42,43,45,48,50,51,53,54,57] on 2586 procedures (1276 robotic and 1310 laparoscopic), with a lower number of pneumonias in the robotic group (RD = −0.038, p = 0.003, 95%CI −0.064; −0.013) and no significant heterogeneity among the studies (I 2 = 0%, p = 0.726). RLN paralysis was reported by 14 Authors [23,29,32,33,37,38,40,42,45,48,50,51,53,57] on 2370 procedures (1153 robotic and 1217 laparoscopic), with no significant differences between the two approaches (OR = 0.760, p = 0.258, 95%CI 0.473, 1.223), but with a significant heterogeneity among the studies (I 2 = 69.109%, p < 0.0001).…”

“…Ivor-Lewis procedure was performed in four studies [ 39 , 49 , 51 , 56 ], McKeown esophagectomy in ten studies [ 34 , 42 , 43 , 53 , 54 , 57 , 58 , 59 , 60 , 61 ] while nine studies did not specify the intervention [ 31 , 32 , 33 , 40 , 47 , 48 , 50 , 52 , 55 ].…”

“…Intraoperative outcomes are shown in Figure 2 . Operative time was reported by 15 Authors [ 23 , 25 , 26 , 28 , 29 , 30 , 31 , 35 , 37 , 40 , 45 , 46 , 49 , 54 , 57 ] on 2690 procedures (which of 1089 robotic and 1601 laparoscopic), demonstrating a lower operative time in the laparoscopic group (MD = 31, p = 0.003, 95%CI 10.743; 52.478), with a significant heterogeneity among the studies (I 2 = 93.720%, p < 0.0001). Estimated blood loss was analysed by 14 Authors [ 21 , 23 , 28 , 29 , 33 , 37 , 38 , 39 , 42 , 48 , 50 , 51 , 53 , 57 ], on 1977 procedures (which of 995 robotic and 982 laparoscopic), demonstrating no significant differences between the two approaches (MD = 1.673, p = 0.805, 95%CI −11.638; 14.985), with no heterogeneity among the studies (I 2 = 0%, p = 0.760).…”