Robot-Assisted Mckeown Esophagectomy is Feasible After Neoadjuvant Chemoradiation. Our Initial Experience

Abstract

Neoadjuvant chemoradiation has become the standard of care for esophageal cancer, especially for middle third esophageal lesions and those with squamous histology. Although more and more thoracic surgeons and surgical oncologists have now shifted to video-assisted and robot-assisted thoracoscopic esophagectomy; there is still limited experience for the use of minimal-assisted approaches in patients undergoing surgery after neoadjuvant chemoradiation. Most surgeons have concerns of feasibility, safety, and oncological outcomes as well as issues related to difficult learning curve in adopting robotic esophagectomy in patients after chemoradiation. We present our initial experience of Robot-Assisted Mckeown Esophagectomy in 27 patients after neoadjuvant chemoradiation, from May 2013 to October 2014. All patients underwent neoadjuvant chemoradiation to a dose of 50.4 Gy/25Fr with concurrent weekly cisplatin, followed by reassessment with clinical examination and repeat FDG PET/CT 6 weeks after completion of chemoradiation. Patients with progressive disease underwent palliative chemotherapy while patients with either partial or significant response to chemoradiation underwent Robot-Assisted Mckeown Esophagectomy with esophageal replacement by gastric conduit and esophagogastric anastomosis in the left neck. Out of 27 patients, 92.5 % patients had stage cT3/T4 tumours and node-positive disease in 48.1 % on imaging. Most patients were middle thoracic esophageal cancers (23/27), with squamous histology in all except for one. All patients received neoadjuvant chemoradiation and subsequently underwent Robot Assisted Mckeown Esophagectomy. The average time for robot docking, thoracic mobilization and total surgical procedure was 13.2, 108.4 and 342.7 min, respectively. The procedure was well tolerated by all patients with only one case of peri-operative mortality. Average ICU stay was 6.35 days (range 3-9 days). R0 resection rate of 96.3 % and average lymph node yield of 18 could be achieved. Pathological node negativity rate (pN0) and complete response (pCR) were 66.6 and 44.4 %, respectively. In the initial cases, four patients had to be converted to open due technical reasons or intraoperative complications. The present study, with shorter operative times, similar ICU stay, overall low morbidity, and mortality and optimal oncological outcomes suggest that robot-assisted thoracic mobilization of esophagus in patients with prior chemoradiation is feasible and safe with acceptable oncological outcomes. It has a shorter learning curve and hence allows for a transthoracic minimally invasive transthoracic esophagectomy to more and more patients, otherwise unfit for conventional approach.

Robot‐assisted minimally invasive esophagectomy for esophageal cancer: Meticulous surgery minimizing postoperative complications

“…Only four studies reported recurrent nerve injury with the average rate of 4.2% 31,33,37,39 . On the other hand, recurrent nerve injury rates in the case series of McKeown RAMIE were reported to be 2.9%‐29% with the average rate of 15.9% 12,13,15–26 . However, it should be considered that McKeown and Ivor Lewis procedures have different operative indications and the attitudes toward upper mediastinal dissection would be different, which could affect the rate of recurrent nerve palsy and other complications.…”

“…31,33,37,39 On the other hand, recurrent nerve injury rates in the case series of McKeown RAMIE were reported to be 2.9%-29% with the average rate of 15.9%. 12,13,[15][16][17][18][19][20][21][22][23][24][25][26]…”

“…[12][13][14] Table 1 lists case series studies of McKeown RAMIE including 10 cases or more. 12,13,[15][16][17][18][19][20][21][22][23][24][25][26] In most studies, squamous cell carcinoma was the predominant histological type. Median or average EBL was 100 mL or more in all studies reporting EBL with maximum median EBL of 950 mL.…”

Robot-Assisted Esophagectomy After Neoadjuvant Chemoradiation—Current Status and Future Prospects

“…The study suggested that robot-assisted thoracic mobilization of esophagus was feasible and safe after neoadjuvant chemoradiation in middle third esophageal cancers and also had a shorter learning curve compared with conventional VATS esophagectomy. The procedure had lower ICU stay and postoperative complications with optimal oncological results [38].…”

Comparison of the short-term outcomes of robot-assisted minimally invasive, video-assisted minimally invasive, and open esophagectomy

“…Ma et al confirm that the neo-adjuvant therapy does not appear to negatively impact the therapeutic outcome of MIE (22). Goel et al also suggest that robot-assisted surgery was feasible and safe following neo-adjuvant therapy, with acceptable oncological outcomes and a shorter learning curve compared with the VAMIE (23). Further development of RAMIE could reduce the overall rate of complications caused by the neo-adjuvant therapy in the future.…”