Lymph node dissection around left recurrent laryngeal nerve: robot-assisted vs. video-assisted McKeown esophagectomy for esophageal squamous cell carcinoma

Abstract

Objective This study investigated the advantages of robot-assisted McKeown esophagectomy (RAME) for extensive superior mediastinal lymph node dissection (LND) versus video-assisted McKeown esophagectomy (VAME). Methods The cases of 184 consecutive esophageal squamous cell carcinoma (ESCC) patients who underwent minimally invasive McKeown esophagectomy (109 with RAME, 75 with VAME) performed by a single surgical group between June 2017 and December 2019 were retrospectively reviewed. Results Overall, 59.8% (110/181) patients (70 treated with RAME, 40 treated with VAME; 64.2% vs. 53.3%, respectively, p = 0.139) underwent complete LND around the left recurrent laryngeal nerve (RLN) by pathological assessment. Cumulative sum plots showed increased numbers of LND around the left RLN (3.6 ± 2.0 vs. 5.4 ± 2.7, p = 0.008) and a decreased incidence of recurrent nerve injury (27.9% vs. 7.4%, p = 0.037) after RAME learning curve. Despite similar overall LND results (30.6 ± 10.2 vs. 28.1 ± 10.2, p > 0.05), RAME yielded more LND (5.4 ± 2.7 vs. 4.4 ± 2.2, p = 0.016) and a greater proportion of lymph node metastases (37.0% vs. 7.5%) around the left RLN but induced a lower proportion of recurrent nerve injuries (7.4% vs. 22.5%, p = 0.178) compared with VAME. Further analysis revealed that the complete LND around the left RLN was associated with recurrent nerve injury in the RAME (20.0% vs. 5.1%, p = 0.035) and VAME (22.5% vs. 5.7%, p = 0.041) groups but did not affect other clinical outcomes including surgical duration, intraoperative blood loss, postoperative intensive care unit stay, hospital stay, and other complications. Conclusions For patients with ESCC, RAME has great advantages in LND around the left RLN and recurrent nerve protection after learning curve of robotic esophagectomy.

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

“…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 ].…”

“…Postoperative bleeding was reported by 4 Authors [ 33 , 34 , 57 , 61 ] on 1556 procedures (489 robotic and 1067 laparoscopic), demonstrating no significant differences between the two groups (OR = 0.952, p = 0.882, 95%CI 0.494, 1.831) and no significant heterogeneity among the studies (I 2 = 0%, p = 0.898). 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).…”

“…Oncologic outcomes are shown in Figure 4 . Mean number of harvested nodes was reported by 17 Authors [ 31 , 34 , 38 , 40 , 43 , 48 , 49 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 ] on 10,707 procedures (which of 3566 robotic and 7141 laparoscopic), demonstrating a higher number in the harvested nodes during the robotic approach (MD = 1.307, p = 0.001, 95%CI 0.553; 2.060), with a significant heterogeneity among the studies (I 2 = 74.857%, p < 0.0001). The number of complete resection (R0 resection) was reported by 12 Authors [ 32 , 38 , 48 , 49 , 50 , 52 , 53 , 56 , 57 , 58 , 60 , 61 ] on 2940 procedures (which of 1469 robotic and 1471 laparoscopic), with no significant differences between the two procedures (RD = 0.005, p = 0.473, 95%CI −0.009; 0.019), and no significant heterogeneity among the studies (I 2 = 20.790%, p = 0.258).…”

“…Excluding the two studies in which the surgical procedures was not clearly described [ 52 ] or in which a hybrid approach was adopted [ 33 , 55 ], this subgroup analysis included 21 studies [ 31 , 32 , 33 , 34 , 38 , 40 , 42 , 43 , 47 , 48 , 49 , 50 , 51 , 53 , 54 , 56 , 57 , 58 , 59 , 60 , 61 ].…”

“…After excluding four studies about Ivor-Lewis procedure [ 38 , 49 , 51 , 56 ] and other nine in which Ivor-Lewis and Mckeown were not separately analysed [ 31 , 32 , 33 , 40 , 47 , 48 , 50 , 52 , 55 ], ten studies [ 34 , 42 , 43 , 53 , 54 , 57 , 58 , 59 , 60 , 61 ] were included in the subgroup analysis according to Mckeown procedure.…”