Robot-assisted Minimally Invasive Thoracolaparoscopic Esophagectomy Versus Open Transthoracic Esophagectomy for Resectable Esophageal Cancer

Abstract

Background: The standard curative treatment for patients with esophageal cancer is perioperative chemotherapy or preoperative chemoradiotherapy followed by open transthoracic esophagectomy (OTE). Robot-assisted minimally invasive thoracolaparoscopic esophagectomy (RAMIE) may reduce complications. Methods: A single-center randomized controlled trial was conducted, assigning 112 patients with resectable intrathoracic esophageal cancer to either RAMIE or OTE. The primary endpoint was the occurrence of overall surgery-related postoperative complications (modified Clavien-Dindo classification grade 2–5). Results: Overall surgery-related postoperative complications occurred less frequently after RAMIE (59%) compared to OTE (80%) [risk ratio with RAMIE (RR) 0.74; 95% confidence interval (CI), 0.57–0.96; P = 0.02]. RAMIE resulted in less median blood loss (400 vs 568 mL, P <0.001), a lower percentage of pulmonary complications (RR 0.54; 95% CI, 0.34–0.85; P = 0.005) and cardiac complications (RR 0.47; 95% CI, 0.27–0.83; P = 0.006) and lower mean postoperative pain (visual analog scale, 1.86 vs 2.62; P < 0.001) compared to OTE. Functional recovery at postoperative day 14 was better in the RAMIE group [RR 1.48 (95% CI, 1.03–2.13; P = 0.038)] with better quality of life score at discharge [mean difference quality of life score 13.4 (2.0–24.7, p = 0.02)] and 6 weeks postdischarge [mean difference 11.1 quality of life score (1.0–21.1; P = 0.03)]. Short- and long-term oncological outcomes were comparable at a medium follow-up of 40 months. Conclusions: RAMIE resulted in a lower percentage of overall surgery-related and cardiopulmonary complications with lower postoperative pain, better short-term quality of life, and a better short-term postoperative functional recovery compared to OTE. Oncological outcomes were comparable and in concordance with the highest standards nowadays.

Postoperative complications of minimally invasive esophagectomy for esophageal cancer

“…The median incidences of anastomotic leakage in all reports, except for the reports of robotic-assisted McKeown MIE, were less than the 11.4% indicated in the ECCG report. The incidence of anastomotic leakage was relatively high in two of the three reports of robotic-assisted McKeown MIE,50,52…”

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

“…Auch hier konnte in prospektiv randomisierten Studien eine Reduktion pulmonaler Komplikationen beim laparoskopischen Vorgehen in Vergleich zur offenen Chirurgie gezeigt werden [10]. Auch in Bezug auf die roboterassistierte Ösophagusresektion existieren Daten einer prospektiv randomisierten Studie, die ebenfalls eine Reduktion postoperativer Komplikationen, reduzierte postoperative Schmerzen und eine bessere Lebensqualität zeigte [11]. Absolut gesehen zeigten sich in dieser Studie relativ hohe Komplikationsraten in beiden Gruppen, insbesondere die angegebene Anastomoseninsuffizienzrate von 24 % in der robotischen Gruppe erscheint vergleichsweise hoch.…”

“…Zusammenfassend stellt die robotische Ösophagusresektion in unserer klinischen Routine ein etabliertes Verfahren dar, in Studien konnte eine Überlegenheit, insbesondere in Bezug auf pulmonale Komplikationen gezeigt werden. Aktuell existiert mit dem ROBOT-Trial nur eine vergleichende prospektiv randomisierte Studie [11]. Mit Spannung werden diesbezüglich die Ergebnisse einer rekrutierenden Studie erwartet, die den Vergleich MIE/RAMIE bei resektablem Plattenepithelkarzinom untersucht [15].…”

Paravertebral catheter versus EPidural analgesia in Minimally invasive Esophageal resectioN: a randomized controlled multicenter trial (PEPMEN trial)

“…Thoracic epidural analgesia is the current gold standard for pain control in this context, as it was shown to be superior to systemic opioids in terms of pain control and pulmonary complications after open esophagectomy [5,6]. However, over the last decades, minimally invasive esophagectomy (MIE) is increasingly adopted, which is associated with less postoperative pain when compared to open surgery [7][8][9]. Furthermore, enhanced recovery protocols have been introduced for esophagectomy, aiming at fast mobilization and recovery after MIE [10][11][12].…”