Initial experiences of the transthoracic esophagectomy for esophageal cancer via intercostal approach with the single-port robotic surgical system.

MP50-14 SINGLE PORT VS MULTI PORT ROBOTIC RENAL SURGERY: ANALYSIS OF PERIOPERATIVE OUTCOMES FOR EXCISION OF HIGH AND LOW COMPLEXITY RENAL MASSES

Robot-assisted and conventional minimally invasive esophagectomy are associated with better postoperative results compared to hybrid and open transthoracic esophagectomy

IntroductionTransthoracic esophagectomy is a highly complex and sophisticated procedure with high morbidity rates and a significant mortality. Surgical access has consistently become less invasive, transitioning from open esophagectomy to hybrid esophagectomy (HE) then to totally minimally invasive esophagectomy (MIE), and most recently to robot-assisted minimally invasive esophagectomy (RAMIE), with each step demonstrating improved patient outcomes. Aim of this study with more than 600 patients is to complete a propensity-score matched comparison of postoperative short-term outcomes after highly standardized RAMIE vs. HE in a European high volume center.Patients and MethodsSix hundred and eleven patients that underwent transthoracic Ivor–Lewis esophagectomy for esophageal cancer between May 2016 and May 2021 were included in the study. In January 2019, we implemented an updated robotic standardized anastomotic technique using a circular stapler and ICG (indocyanine green) for RAMIE cases. Data were retrospectively analyzed from a prospectively maintained IRB-approved database. Outcomes of patients undergoing standardized RAMIE from January 2019 to May 2021 were compared to our overall cohort from May 2016–April 2021 (HE) after a propensity-score matching analysis was performed.ResultsSix hundred and eleven patients were analyzed. 107 patients underwent RAMIE. Of these, a total of 76 patients underwent a robotic thoracic reconstruction using the updated standardized circular stapled anastomosis (RAMIE group). A total of 535 patients underwent HE (Hybrid group). Seventy patients were propensity-score matched in each group and analysis revealed no statistically significant differences in baseline characteristics. RAMIE patients had a significantly shorter ICU stay (p = 0.0218). Significantly more patients had no postoperative complications (Clavien Dindo 0) in the RAMIE group [47.1% vs. 27.1% in the HE group (p = 0.0225)]. No difference was seen in lymph node yield and R0 resection rates. Anastomotic leakage rates when matched were 14.3% in the hybrid group vs. 4.3% in the RAMIE group (p = 0.07).ConclusionOur analysis confirms the safety and feasibility of RAMIE and HE in a large cohort after propensity score matching. A regular postoperative course (Clavien–Dindo 0) and a shorter ICU stay were seen significantly more often after RAMIE compared to HE. Furthermore it shows that both procedures provide excellent short-term oncologic outcomes, regarding lymph node harvest and R0 resection rates. A randomized controlled trial comparing RAMIE and HE is still pending and will hopefully contribute to ongoing discussions.

BackgroundThe previously published ROBOT trial demonstrated that robot assisted minimally invasive esophagectomy (RAMIE) is associated with a lower percentage of postoperative complications compared to open esophagectomy (OTE) for patients with esophageal cancer. The implications of these results on healthcare costs are important given the increased attention for cost-reduction in healthcare. Therefore the aim of this study was to report the hospital costs of RAMIE compared to OTE as treatment for esophageal cancer. MethodsThe ROBOT trial randomized 112 patients with esophageal cancer between RAMIE and OTE through January 2012 and August 2016 in a single tertiary care academic centre in the Netherlands. The primary outcome of the current study was hospital costs from the day of esophagectomy until 90 days after discharge based on Time-Driven Activity-Based Costing methodology. Secondary outcomes included the incremental cost-effectiveness ratio per complication prevented and risk factors for increased hospital costs. ResultsOf the 112 included patients, 109 patients underwent an esophagectomy, of whom 54 RAMIE and 55 OTE. The mean total hospital costs were comparable between RAMIE €40211 and OTE €39495 (mean difference €-715; bias-corrected and accelerated confidence interval € −14831 to 14783, p = 0.932). At a willingness-to-pay threshold of €20.000 to €25.000 (i.e. estimated additional costs to the hospital to treat patients with a complication) RAMIE had a probability 62%–70% of being cost effective to prevent postoperative complications. In multivariable regression analysis, major postoperative complications were the main driver of hospital costs after esophagectomy (€31839, p = 0.009). ConclusionIn this randomized trial RAMIE resulted in fewer postoperative complications compared to OTE without increasing total hospital costs.

Background: Robot-assisted simple prostatectomy (RASP) has emerged as a safe surgical treatment for patients with benign prostatic hyperplasia with large glands (>80 mL). Several studies reported on perioperative outcomes of RASP by the standard multiport (MP) da Vinci® robotic system approach. Studies conducted on RASP utilizing the novel single-port (SP) da Vinci SP robotic platform (Intuitive Surgical, Sunnyvale, CA) are scarce. We aimed to compare intraoperative and short-term postoperative outcomes between the da Vinci MP and SP robots for patients undergoing RASP in a referral center. Methods: In this retrospective study, we reviewed all patients who underwent RASP using MP or SP robot from September 2016 to March 2021. Intraoperative data, overall 30-day complications, complications by Clavien-Dindo classification, and 90-day readmission and reoperation rates were assessed and compared between the two groups using appropriate statistical methods. Results: Seventy-five patients who underwent RASP were identified. Of these, 47 were in the MP group and 28 were in the SP. Compared with SP, mean operative time in MP group was 216.6 vs 232.4 minutes (p = 0.39), estimated blood loss was 195.7 vs 227.1 mL (p = 0.43), and length of stay was 2 vs 2.5 days (p = 0.45). There was a trend toward higher overall complication rate in SP group vs MP (42.86% vs 21.28%, p = 0.09). There were no significant differences in the readmission (17.02% vs 10.71%, p = 0.52) and reoperation (2.1% vs 7.14%, p = 0.34) rates between MP vs SP group. Conclusion: SP-RASP is safe and shows equivalent perioperative outcomes when compared with the MP robotic system. A marginal increase of complication rate was recorded in the SP group; however, this did not demonstrate statistical significance.

The hinotori™ Surgical Robot System is an alternative to the da Vinci Surgical System for performing robot-assisted minimally invasive esophagectomy (RAMIE). We introduce our setup and surgical procedure for RAMIE using the hinotori™ Surgical Robot System (H-RAMIE) and present its outcomes and the team's familiarization with RAMIE using the second robotic system. With the patient in the left semiprone position, the patient cart was rolled in from the right cranial side of the patient. Teaching pivots were optimized for upper mediastinal dissection. An assistant's sealing device was frequently utilized for middle and lower mediastinal dissections. In addition to the analysis of all the experienced cases, a matched retrospective comparative analysis of short-term outcomes was performed between H-RAMIE and RAMIE using the da Vinci Xi (D-RAMIE). The learning curves of the cockpit time, setting time, and ratio of idle time-to-cockpit time of H-RAMIE were analyzed using the cumulative sum method. H-RAMIE was performed in 45 patients, including 11 salvage esophagectomies. The incidences of postoperative complications of Clavien-Dindo (CD) grades ≥ 2 and ≥ 3a were 55.6 and 20%, respectively; no postoperative mortality was observed. The median postoperative hospital stay was 25days. By matching, 29 cases of H-RAMIE and D-RAMIE were included in the comparative analysis. H-RAMIE demonstrated a longer thoracic part time than D-RAMIE; however, no significant differences were observed between both groups regarding the incidence of postoperative complications of CD grades ≥ 2 and ≥ 3a, incidence of recurrent laryngeal nerve palsy of all grades or the length of postoperative hospital stay. Learning curve analyses suggested that approximately 9-13 cases were required to reach an efficiency plateau in H-RAMIE. The hinotori™ can be safely introduced as the second robotic system for RAMIE, requiring approximately 9-13 cases to reach an efficiency plateau in an institution with experience in RAMIE.

BackgroundNo population-based studies comparing long-term survival after transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) exist. This study aimed to compare the 5-year survival of esophageal cancer patients undergoing THE or TTE in a population-based nationwide setting.MethodsThis study included all curatively intended THE and TTE for esophageal cancer in Finland during 1987–2016, with follow-up evaluation until 31 December 2019. Cox proportional hazard models provided hazard ratios (HRs) with 95% confidence intervals (CIs) of 5-year and 90-day mortality. The results were adjusted for age, sex, year of operation, comorbidities, histology, neoadjuvant treatment, and pathologic stage.ResultsA total of 1338 patients underwent THE (n = 323) or TTE (n = 1015). The observed 5-year survival rate was 39.3% after THE and 45.0% after TTE (p = 0.072). In adjusted model 1, THE was not associated with greater 5-year mortality (HR 0.99; 95% CI 0.82–1.20) than TTE. In adjusted model 2, including T stage instead of pathologic stage, the 5-year mortality hazard rates after THE (HR 0.87, 95% CI 0.72–1.05) and TTE were comparable. The 90-day mortality rate for THE was higher than for TTE (adjusted HR 0.72; 95% CI 0.45–1.14). In subgroup analyses, no differences between THE and TTE were observed in Siewert II gastroesophageal junction cancers, esophageal cancers, or pN0 tumors, nor in the comparison of THE and TTE with two-field lymphadenectomy. The sensitivity analysis, including patients with missing patient records, who underwent surgery during 1996–2016 mirrored the main analysis.ConclusionsThis Finnish population-based nationwide study suggests no difference in 5-year or 90-day mortality after THE and TTE for esophageal cancer.

Video-assisted thoracoscopic surgery has been identified as priori choice compared with open approaches in esophageal cancer surgery. With the developments in the Da Vinci robotic system, the robot-assisted minimally invasive esophagectomy (RAMIE) has been increasingly popular. However, whether RAMIE could be a better choice over thoraco-laparoscopic minimally invasive esophagectomy (TLMIE) is unclear. The clinicopathological characteristics of patients who received RAMIE or TLMIE with modern two-field lymph node dissection in Sun Yat-sen University Cancer Center between Jan 2016 to Jan 2018 were retrospectively retrieved. The 1:1 propensity score match analysis was performed to compare the short-term effectiveness and safety between the two groups. Two hundred and fifteen esophageal squamous cell carcinoma (ESCC) patients received RAMIE (101 patients) or TLMIE (114 patients) were included in the analysis. After a 1:1 propensity score matching, 108 patients (54 pairs) who received RAMIE or TLMIE displayed no significant variance in baseline clinicopathological characteristics. No significant difference in operative time, intraoperative blood loss, number of resected lymph nodes, and R0 resection rates were observed between the matched groups. However, the recurrent laryngeal nerve protection was better in RAMIE group (P=0.021). Nevertheless, both the incidences of common postoperative complications and length of ICU (hospital) stay were similar in two groups. The average total (P=0.009) and daily (P=0.028) expenses of RAMIE were higher. In general, RAMIE could benefit patients by providing better recurrent laryngeal nerve protection. In order to promote the applications of RAMIE, more efforts should be made to reduce the costs by the social and medical insurance agencies.

Since the first reported clinical application of robot-assisted minimally invasive esophagectomy (RAMIE) in the early 2000s, RAE has gained increasing popularity worldwide in the recent 20 years. Although RAE is not yet regarded as standard surgical treatment for esophageal cancer, a lot of institutions have reported the safety and feasibility of robotic system in both transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE). Most of the studies focused on the surgical outcomes and recent oncologic results, the RAMIE have shown with short blood loss and effective early oncologic outcomes: R0 resection rate approximately 95% and rare locoregional recurrence. This may show that RAMIE has a tendency of improved long-term survival for esophageal cancer. Thus, the objective of this study is to report the early oncological control results of robot assisted esophagectomy, based on the previous publications and our initial experience. Key words: Esophageal cancer; Robot-assisted minimally invasive esophagectomy; Oncological outcome

There is no study comparing open esophagectomy (OE), video-assisted thoracic surgery (VATS), and robot-assisted minimally invasive esophagectomy (RAMIE) in a single institution. This study included 272 patients who underwent subtotal esophagectomy divided into three groups: OE (n=110), VATS (n=127), and RAMIE (n=35) groups. Moreover, short-term outcomes were compared. Overall complications (CD≥II) were significantly less in the RAMIE than the OE and VATS groups. Recurrent laryngeal nerve paralysis (CD≥II) was significantly lower in the RAMIE than the OE group (p=0.026) and tended to be lower than that in the VATS group (p=0.059). The RAMIE group had significantly less atelectasis (CD≥I and II), pleural effusion (CD≥I and II), arrhythmia (CD≥II), and dysphagia (CD≥II), than both the OE and VATS groups. RAMIE reduced overall postoperative complications after esophagectomy compared with both OE and VATS.

Robotic surgical systems with full articulation of instruments, tremor filtering, and motion scaling can potentially overcome the procedural difficulties in endoscopic surgeries. However, whether robot-assisted minimally invasive esophagectomy (RAMIE) can overcome anatomical difficulties during thoracoscopic esophagectomy remains unclear. This study aimed to clarify the anatomical and clinical factors that influence the difficulty of RAMIE in the thoracic region. Forty-five patients who underwent curative-intent RAMIE with upper mediastinal lymph node dissection for esophageal cancer were included. Using preoperative computed tomography images, we calculated previously reported anatomical indices to assess the upper mediastinal narrowness and vertebral body projections in the middle thoracic region. The factors influencing thoracic operative time were then investigated. During the thoracic procedure, the median operative time was 215 (124-367) min and the median blood loss was 20 (5-190) mL. Postoperatively, pneumonia, anastomotic leakage, and recurrent laryngeal nerve palsy occurred in 17.8%, 2.2%, and 6.7% of the patients, respectively. The multiple linear regression model revealed that a narrow upper mediastinum and greater blood loss during the thoracic procedure were significant factors associated with a prolonged thoracic operative time (P = 0.025 and P < 0.001, respectively). Upper mediastinal narrowing was not associated with postoperative complications. A narrow upper mediastinum was significantly associated with a prolonged thoracic operative time in patients with RAMIE.

Currently 4 surgical techniques are performed for transthoracic esophagectomy (open esophagectomy (OE), hybrid esophagectomy (HE), conventional minimally invasive esophagectomy (MIE) and robot assisted minimally invasive esophagectomy (RAMIE). Aim of this study was to compare these 4 different esophagectomy approaches regarding postoperative complications and short term oncologic outcomes. Between 2008 and 2019, consecutive patients who underwent esophagectomy with gastric conduit reconstruction were included in this single center study. The primary outcome of this study was the incidence of postoperative complications. Overall 422 patients (OE (n = 107), HE (n = 101), MIE (n = 91) and RAMIE (n = 123)) were evaluated. Uncomplicated postoperative course was observed in 27% (OE), 34% (HE), 53% (MIE), and 63% (RAMIE) of patients (p &amp;lt; 0.001). Pulmonary complications were observed in 57% (OE), 44% (HE), 28% (MIE), and 21% (RAMIE) of patients (p &amp;lt; 0.001). Cardiac complications were present in 25% (OE), 23% (HE), 9% (MIE), and 11% (RAMIE) of patients (p &amp;lt; 0.001). MIE and RAMIE were associated with fewer wound infections (p &amp;lt; 0.001). Median hospital stay was shorter for MIE and RAMIE went compared to OE and HE (p &amp;lt; 0.001). The lymph nodes yield differ significantly between the techniques (p &amp;lt; 0.001). Total minimally invasive esophagectomy (MIE, RAMIE) was associated with a lower overall, pulmonary, cardiac and wound complication rate as well as a shorter hospital stay compared to open or hybrid approach (OE, HE). RAMIE resulted in higher lymph node harvest than MIE.

Incidence and management of chylothorax after Ivor Lewis esophagectomy for cancer of the esophagus

BackgroundEsophageal cancer (EC) remains a lethal malignancy with poor survival outcomes despite multimodal therapy. While minimally invasive techniques like video-assisted thoracoscopic esophagectomy (VATE) and robot-assisted minimally invasive esophagectomy (RAMIE) have gained traction over open esophagectomy (OE), their comparative safety, efficacy, and survival benefits in patients receiving neoadjuvant therapy remain underexplored.MethodsWe conducted a Bayesian network meta-analysis on data from seven studies (n=1847 patients) to compare OE, VATE, and RAMIE after neoadjuvant therapy for locally advanced EC. Outcomes included complication rates, operative time, R0 resection, lymph node yield, and 3-year overall survival (OS).ResultsNo significant differences were observed in R0 resection rates (RAMIE vs. OE: OR = 1.03, 95% CI 0.25–4.70; VATE vs. OE: OR = 1.37, 0.67–3.45), lymph node dissection (RAMIE vs. OE: WMD = 1.56, −3.29–6.43; VATE vs. OE: WMD = 1.05, −2.24–4.53), or 3-year OS (VATE vs. OE: HR = 1.14, 0.70–1.85). RAMIE ranked highest for reducing complications (SUCRA = 52.5%), while OE showed shorter operative time (SUCRA = 94.0%). Achieving R0 resection ranking: RAE (SUCRA 47.3%), OE (SUCRA 43.8%), and VATE (SUCRA 8.9%). In lymph node dissection, OE had the highest probability of being superior (59.5%), markedly outperforming RAMIE (21.3%) and VATE (19.2%). Survival outcomes were comparable across all approaches.ConclusionsOE, VATE, and RAMIE demonstrate equivalent oncological efficacy in EC after neoadjuvant therapy. Perioperative advantages differ: RAE may lower complications, whereas OE offers procedural efficiency. Surgical selection should prioritize individualized risk-benefit assessment, anatomical considerations, and institutional expertise. Prospective trials are warranted to validate these findings and refine technique-specific indications.

Background Robotic-assisted minimally invasive esophagectomy (RAMIE) has been increasingly adopted in the world. While its advantages in surgical outcomes are evident, evidence for its long-term efficacy compared to video-assisted thoracoscopic surgery (VATS) remains limited. Methods This study analyzed 574 patients with thoracic esophageal cancer who underwent RAMIE (n = 184) or VATS (n = 390) between January 2017 and December 2023. Using propensity score matching with covariates such as gender, age, PS, tumor location, cTNM stage, and preoperative therapy, 180 patients from each group were compared for short- and long-term outcomes. Results Comparing RAMIE (n = 180) and VATS (n = 180), the operative time was significantly longer for RAMIE (510 min vs. 471 min, p &amp;lt; 0.0001), with no significant differences in R0 resection rate, intraoperative blood loss, or postoperative hospital stay. The incidence of postoperative complications (Clavien-Dindo grade ≥ 2) was similar, but pleural effusion was more frequent in the RAMIE group (9 vs. 2 cases, p = 0.026). While 2-year OS and RFS showed no overall differences, RAMIE demonstrated significantly better 2-year OS for cT4 cases (92.9% vs. 43.8%, p = 0.0163). Recurrence patterns were comparable between the two groups. Conclusion RAMIE may provide long-term benefits over VATS, particularly for cT4 esophageal cancer. Surgical techniques and future directions will be also discussed in my presentation.