Abstract
Aim: Esophagectomy is associated with several post-operative complications (50%-70%) due to surgical trauma. Minimally invasive techniques have therefore been applied to decrease mortality and morbidity. Robot-assisted minimally-invasive esophagectomy (RAMIE) was developed to overcome the drawbacks of the thoraco-laparoscopic approach. The objective of this systematic review is to report some recent experiences and to compare RAMIE with other approaches to esophagectomy, focusing on technical and oncological aspects. Methods: Pubmed, Embase and Scopus databases were searched for “robot-assisted esophagectomy”, “minimally invasive esophagectomy” and “robotic esophagectomy” in January 2020. The study was focused on original papers on totally endoscopic RAMIE in the English language. No statistical procedures (meta-analysis) were performed. Results: Three hundred and twenty studies were identified across the database and after screening and reviewing, 14 were included for final analysis. The overall 90-day post-operative mortality after trans-thoracic esophagectomy ranged from 0% to 9% and did not differ between approaches. Post-operative complications ranged between 24% and 60.9%: respiratory (6.25% to 65%), cardiac (0.8% to 32%), anastomotic leak (3.1% and 37.5%) and vocal cord palsy (9.1%-35%) were the most frequent. The evidence for long-term outcomes is weak, with no significant differences in overall survival, disease-free survival and recurrence identified in comparison with other approaches. The selected papers showed that RAMIE had comparable outcomes between the open and thoraco-laparoscopic approaches within a multimodal treatment pathway. Conclusion: RAMIE also seems to be associated with better lymph node dissection, nerve sparing and quality of life, but larger studies are needed to obtain more evidence.
Highlights
In the multimodal treatment pathway for esophageal carcinoma (EC), esophagectomy still remains an important component for curative and radical treatment
The evidence for long-term outcomes is weak, with no significant differences in overall survival, disease-free survival and recurrence identified in comparison with other approaches
The selected papers showed that Robotassisted minimally-invasive esophagectomy (RAMIE) had comparable outcomes between the open and thoraco-laparoscopic approaches within a multimodal treatment pathway
Summary
In the multimodal treatment pathway for esophageal carcinoma (EC), esophagectomy still remains an important component for curative and radical treatment. Current international guidelines[1,2,3,4,5] recommend combined treatment for patients with localized esophageal or esophagogastric cancer and support the use of minimally invasive surgery such as minimally-invasive thoraco-laparoscopic esophagectomy (MIE) and RAMIE. Post-operative and oncological outcomes after esophagectomy are influenced by surgical volume and optimized by referral to specialized centers .[10] Several concerns have limited acceptance of MIE such as its technical complexity and doubts about its oncological value. From the innovative and pioneering experiences of Giulianotti et al.[12] and Kernstine et al.[13], RAMIE has gained popularity amongst surgeons because it seems to ensure adequate oncological outcomes with lower surgical trauma, and fewer post-operative complications in a stable and comfortable environment[14]. A recent randomized controlled trial (RCT)[14], a meta-analysis[15] and some multicenter retrospective studies[16,17] have demonstrated the safety and oncological adequacy of RAMIE, but other well-designed comparative long-term studies are needed to validate and establish the role of RAMIE
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