Management of resectable esophageal cancer has evolved into a multidisciplinary paradigm centered on multimodality therapy. Historically, induction chemoradiotherapy followed by surgery, as established by the CROSS trial, became the standard of care for locally advanced disease due to improvements in R0 resection rates and overall survival. More recently, the ESOPEC trial reexamined this paradigm in esophageal adenocarcinoma, demonstrating superior survival and improved systemic disease control with perioperative chemotherapy using the FLOT regimen compared with chemoradiotherapy. In parallel, the MATTERHORN trial further advanced perioperative treatment by showing improved event-free survival with the addition of the immune checkpoint inhibitor durvalumab to FLOT chemotherapy. Alongside these systemic therapy advances, surgical management has transitioned toward minimally invasive and robotic-assisted esophagectomy, offering equivalent oncologic outcomes with reduced perioperative morbidity. This review summarizes the evolving evidence from pivotal clinical trials, highlights ongoing studies integrating immunotherapy, and discusses emerging strategies such as adoptive cell transfer which currently is under investigation for metastatic recurrence, but in the future may provide additional treatment options for resectable esophageal cancer.

BackgroundChronic postsurgical pain (CPSP) is a debilitating chronic pain condition that particularly impacts patients undergoing thoracic surgery, with incidence rates of up to 50%. The current understanding of risk factors is limited, and preoperative neurophysiological risk factors that may predict the development of CPSP have not yet been explored. Additionally, the specific neural mechanisms underlying the transition to CPSP are not well characterized. As a novel approach, we propose the use of transcranial magnetic stimulation and electroencephalography, along with other patient and surgical factors, to understand the neurophysiological mechanisms underlying the onset of CPSP after thoracic surgery.ObjectiveThe primary objective of this study is to evaluate the feasibility of our study design to inform a larger observational cohort study. Secondary objectives include exploring preoperative neurophysiological markers along with clinical characteristics associated with a higher risk of developing CPSP, as well as exploring postoperative differences in cortical function between patients who undergo thoracic surgery and develop CPSP compared with those who do not develop CPSP.MethodsA total of 30 participants undergoing video-assisted thoracic surgery or a robotic-assisted thoracic lobectomy, wedge resection, segmental section, or minimally invasive esophagectomy, will be recruited to take part in 2 assessment sessions. The first assessment will take place 2 to 3 weeks before surgery, and the second assessment will take place 3 months after surgery, during which the CPSP diagnosis of each participant will be assessed by the experimenter using a validated definition. Feasibility outcomes include recruitment and retention rates of study participants. The secondary objectives include exploring factors associated with the development of CPSP, as well as examining postoperative differences in neurophysiological measures between patients with and without CPSP. We will consider the following neurophysiological measures for these objectives: transcranial magnetic stimulation measures of short-latency intracortical inhibition, cortical silent period, and motor evoked potentials; electroencephalography measures of resting band activity, event-related desynchronization, and corticomuscular coherence; and quantitative sensory testing of mechanical detection threshold and pressure pain threshold.ResultsThis is an ethics-approved, ongoing study. Initial funding for this study was provided in March 2023. Recruitment for the study began in January 2025. A total of 22 participants have been recruited for the study. We anticipate completing data collection for this study by April 2026, with data analysis to follow.ConclusionsThis protocol details our study design for a feasibility study exploring the neurophysiological markers and patient characteristics associated with the development of CPSP. Demonstration of feasibility is expected to lead to a larger study. Improved understanding of the risk factors and mechanisms underlying CPSP may inform the delivery of targeted therapies and preventive measures to reduce the incidence of CPSP after thoracic surgery.International Registered Report Identifier (IRRID)DERR1-10.2196/81042

Implementation of an Enhanced Recovery After Surgery (ERAS) Protocol for Esophagectomy: An Evaluation in a High-Volume Tertiary Center.

Surgical workflow analysis for Surgomics and context-aware assistance in robot-assisted minimally invasive esophagectomy (RAMIE): a retrospective, single-arm, multicenter annotation and machine learning study.

Despite being highly invasive, esophagectomy remains the mainstay of treatment for early- and intermediate-stage esophageal cancer. With the advancement of minimally invasive techniques, single-port thoraco-laparoscopic esophagectomy has been increasingly applied in clinical practice, offering advantages in terms of improved cosmetic outcomes, reduced postoperative pain, and enhanced recovery. However, the procedure is technically demanding. In addition, the traditional posterior mediastinal route for reconstruction is associated with a relatively high risk of complications, whereas reconstruction via the substernal route may significantly reduce cardiopulmonary morbidity. To evaluate the short-term outcomes of uniportal thoracoscopic and single-incision plus one port laparoscopic minimally invasive esophagectomy combined with direct retrosternal approach for radical esophagectomy. The clinical data of 60 patients who underwent uniportal thoracoscopic and single-incision plus one port laparoscopic minimally invasive esophagectomy combined with direct retrosternal approach for radical esophagectomy between January 2024 and February 2025 were retrospectively analyzed. Perioperative indicators and postoperative follow-up data were recorded in detail. All surgeries were successfully completed with no conversion to open thoracotomy or laparotomy, and no perioperative deaths occurred. The mean operative time was 209.35 ± 28.57min, the mean intraoperative blood loss was 64.17 ± 20.53 mL, and the mean number of lymph nodes dissected was 32.35 ± 11.51. The visual analog scale (VAS) scores for pain at postoperative were 2.20 ± 0.99. The average length of hospital stay was 7.92 ± 2.11 days. Ten patients developed postoperative complications, with a complication rate of 16.67%. Uniportal thoracoscopic and single-incision plus one port laparoscopic minimally invasive esophagectomy combined with direct retrosternal approach is a safe and feasible technique for esophageal cancer, with potential advantages in terms of cosmetic outcomes and reduced postoperative incisional pain.

Abstract Introduction Up to 50% of patients treated with curative esophagectomy for esophageal cancer will develop recurrence. This case underscores the successful management of recurrent signet ring carcinoma in the gastric tube 4 years after successful Mckeown esophagectomy with perioperative FLOT protocol. Case presentation A 35-year-old female presented with a newly discovered 2 cm localized ulcerated lesion in the gastric tube during the 4th year follow up endoscopy after minimally invasive Mckeown esophagectomy. She underwent redo thoracoscopicgastrectomy with colon interposition to restore GIT continuity and achieving R0 resection. Results Surgical pathology revealed signet ring carcinoma with free surgical margins, number of submitted lymph nodes was 2/15 and pathological staging pT4a N1 Mx. Conclusions Recurrent carcinoma after curative esophagectomy needs multidisciplinary team to discuss the different modalities of management. Treatment with curative intent is difficult, because there is a few data in the literature regarding this subject.

Abstract Introduction Paraconduit hernia occurs uncommonly after oesophagectomy, with the displacement of abdominal contents through the post operative hiatus into the thorax. Clinical presentations vary from asymptomatic to life-threatening visceral ischaemia and can present many years post-operatively. As such, they present a dilemma to oesophageal surgeons in respect of diagnosis and appropriate management. A minimally invasive approach has been repeatedly cited as a risk factor for hernia formation. Method A prospectively maintained database of oeospahgectomies performed at our centre was interrogated from 2019–2023. Demographics, operative approach andclinico-pathological data were extracted. Statistical analyses were conducted using MinitabTM v18. Results From 2019–2023 190 oesophagectomies were completed of which 76%(145) were oesoaphgeal and 24% (45) were oesophago-gastric junctional tumours. The mean age was 66 years ( +/- 9.8 years) and male patients represented 78% of cases. The distribution of surgical approach was Minimally invasive oesophagectomy (MIO)65/190, Robotically assisted minimally invasive oesophagectomy (RAMIO)63/190, Open 2/190 and Hybrid 60/190. The overall rate of paraconduit hernia was 11.6% (22/190). 5/22 occurred within 3 months of oesophagectomy and 10/22 presented symptomatically. The most common organ to herniate was the transverse colon in 19 cases, followed by small bowel in 6. The rate of herniation among the different approaches was hybrid 4/60, RAMIO 12/63 and MIO 6/65 p-0.076. Conclusions The rates of paraconduit hernia at our institution are comparable to international standards. The transition towards a more minimally invasive approach to oesophagectomy and the adoption of robotic platforms to achieve it has not significantly impacted the rate of hernia development.

Abstract Introduction Oesophagectomy remains a highly morbid operation, in spite of advances in neoadjuvant approaches, perioperative care, and minimally invasive surgery. Textbook outcome (TBO) is a composite metric assessing surgical quality and perioperative outcomes. Our group has previously demonstrated a survival advantage with a TBO. Additionally, operating by a minimally invasive approach combined with TBO further improves survival. Robotic assisted minimally invasive oesophagectomy (RAMIO) is oncologically safe and may improve perioperative outcomes. This study aims to determine rates of TBO in RAMIO, and compare this with a pre-existing cohort. Method Patients undergoing oesophagectomy from 2011-2024 were included. Only patients undergoing RAMIO were included post-February 2020. Standard clinicopathologic variables were recorded. TBOs were calculated as previously described1. Statistical analyses were performed with jamovi 2.3.28. Results 362 patients underwent oesophagectomy. 93 had a RAMIO, 139 underwent open oesophagectomy (OO) and 130 underwent laparoscopic oesophagectomy (LO). 53% of RAMIO patients achieved a TBO, compared with 19% of OO and 45% LO (p=0.001, 0.34). For the RAMIO group the most common reason for not achieving a TBO was a post-operative complication (39%), followed by a prolonged length of stay (19%), similar to the non-RAMIO group (32% and 28% respectively). In the RAMIO group there were no associations between age, ASA status, patient sex and neoadjuvant regimen and the likelihood of achieving a TBO. Conclusions The introduction of RAMIO incrementally improve TBO rates, particularly compared with OO. As the use of RAMIO expands, there may be a corresponding incremental impact on long-term oncologic outcomes.

Abstract Aim To develop a risk prediction model for major complications following robotic assisted minimally invasive oesophagectomy (RAMIO), using early postoperative physiological markers. Method A retrospective cohort study was conducted on patients undergoing RAMIO (Ivor-Lewis or McKeown approach) between May 2022 and March 2025. Clinical, inflammatory, and haemodynamic variables within the first 72 hours post-operatively were extracted. The primary outcome was the development of major complications (Clavien-Dindo grade ≥IIIb). Univariate analysis identified candidate predictors, which were entered into multivariable logistic regression. Model performance was assessed using area under the receiver operating characteristic curve (AUC), Hosmer-Lemeshow goodness-of-fit, and McFadden’s Pseudo R². Results Among 168 RAMIO patients, 19 (11.3%) developed complications of Clavien-Dindo grade ≥IIIb. In multivariate analysis of early (<72h post-operatively) variables, peak WCC >17.1 (OR 12.65, p < 0.001), combined drain output >639 ml/24h (OR 5.45, p = 0.008), and noradrenaline use (OR 3.32, p = 0.037) were independently associated with major complications. The model demonstrated strong discrimination (AUC = 0.84, 95% CI 0.75–0.93) and good calibration (Hosmer-Lemeshow p = 0.76). Conclusions Early postoperative variables, particularly WCC, drain output, and noradrenaline use, independently predict major complications following RAMIO. This model provides a practical, real-time tool to support early risk stratification and targeted intervention. Integration into enhanced recovery protocols and validation in external cohorts are warranted to refine its clinical utility.

Abstract Aim This study aimed to compare demographics, outcomes and costs of 50 consecutive unselected RAMIO and MIO cases at a single centre. Method Retrospective data was collected on cases performed by the same surgeons, using the same anastomotic technique and equipment (to reduce operator variability) between 2021 and 2025 and analysed using SPSS. MIO and RAMIO were carried out on alternate weeks due to limited access to robotics. Results There was no significant difference in age, smoking status or BMI between RAMIO and MIO groups. There was a difference in ASA (84% RAMIO ASA 3 versus 26.5% MIO p<.001), however, cardiovascular/respiratory co-morbidities were similar (p.15). Median operating time was 381 minutes RAMIO (IQR 353-409), MIO 282 (IQR 250-351) p.002, length of stay 11 days RAMIO (IQR 9-13), 9 MIO (IQR 8-12) p.046. There was no significant difference in rate of anastomotic leaks (RAMIO 2% n=1 requiring stent, MIO 6%,p.617) or re-operation (RAMIO 2%, MIO 6%,p.61). RAMIO had a higher rate of clear circumferential margins (83.7% versus MIO 76%), similar median lymph node yields (IQR 22-36, MIO IQR 23-33.75). Less RAMIO patients were referred for adjuvant radiotherapy (16%, MIO 24%). Cost of consumables and post operative hospital stay were similar (p.81). Conclusions This study comparing demographically similar RAMIO and MIO cases found RAMIO had a longer operating time with no difference in post operative complication rates. The cost per procedure was comparable, allowing the for the initial cost of the robotic platform. There was a trend towards improved oncological outcomes.

Abstract Aim There is a significant learning curve associated with performing robot-assisted minimally invasive oesophagectomy (RAMIO). The aim of this study was to demonstrate comparable outcomes when using the same, reproducible anastomotic technique as minimally invasive oesophagectomy (MIO). Method This study included fifty consecutive MIO and RAMIO cases performed between October 2022 and February 2025 by one surgeon, in a single tertiary centre. Data was collected retrospectively. The same end to side anastomotic technique (Medtronic DST Series EEA OrVil) was used for all cases. Demographic, surgical, and oncological outcomes were assessed. Data was analysed in excel using SPSS version 30. Results There was no significant difference in patient demographics between RAMIO and MIO groups. Median operative time was 381 minutes (RAMIO IQR 353- 409) and 282 minutes (MIO IQR 250-351) p=0.002. Median length of stay was 12 days (RAMIO IQR 10-14) and 10 days (MIO IQR 9-13) (p=0.047). There was no difference in post-operative complication rate: anastomotic leak rate (RAMIO 2%, MIO 6% p=0.617), staple line leak (RAMIO 0%, MIO 2% p=1), chyle leak (RAMIO 2%, MIO 0% p=1), and pneumonia (RAMIO 32%, MIO 22% p=0.3). RAMIO had a higher rate of R0 resections, clear circumferential margins and lymph node yield (R0 RAMIO 83.7%, MIO 76% p=0.34, clear circumferential margins RAMIO 83.7%, MIO 76% p=0.34, median lymph node RAMIO 29 IQR 22-36, MIO 28.5 IQR 23-33.75 p .63). Conclusions These comparable outcomes demonstrate that using a reproducible anastomotic technique can help to reduce the learning curve when transitioning from MIO to RAMIO.

BackgroundThe treatment of esophageal cancer requires optimized surgical approaches to improve patient outcomes. Minimally invasive esophagectomy (MIE) has demonstrated advantages compared to open procedures, but the difference in efficacy of single-incision versus multi-incision techniques under various reconstruction routes remains unclear. This retrospective propensity-weighted study aimed to evaluate the perioperative outcomes and short-term functional recovery between single-incision laparo-thoracoscopic MIE with retrosternal reconstruction (SIMIE-RS) and multi-incision MIE with posterior mediastinal reconstruction (MIMIE-PM) in patients with esophageal cancer.MethodsThis retrospective study included 339 patients with esophageal cancer who underwent McKeown esophagectomy. The inverse probability of the treatment weighting (IPTW) approach was employed to assess outcome between SIMIE-RS and MIMIE-PM. The primary endpoints included postoperative complications, functional recovery parameters, and perioperative outcomes. Secondary endpoints included oncological adequacy, hospital length of stay, and quality of life indicators.ResultsPulmonary complications were markedly reduced in the SIMIE-RS group as compared to the MIMIE-PM group, with a lower incidence of pneumonia (0.9% vs. 5.5%; P=0.02). Postoperative pain control was substantially improved in the SIMIE-RS group, who exhibited lower visual analog scale scores at 24 hours (3.1±1.0 vs. 7.5±1.1; P<0.001) and 72 hours (1.6±1.1 vs. 3.3±1.2; P<0.001) as compared to the MIMIE-PM group. SIMIE-RS also provided greater functional recovery, with superior forced expiratory volume in 1 second (FEV1) preservation at 1 month (3.2±0.5 vs. 2.4±0.6; P<0.001) and reduced reflux symptoms (1.2±0.5 vs. 1.8±0.9; P<0.001). Hospital length of stay was significantly shorter in the SIMIE-RS group than in the MIMIE-PM group (7.0±1.6 vs. 9.7±1.5 days; P<0.001). The safety profiles of the SIMIE-RS group and MIMIE-PM group were comparable in terms of surgery-related complications, including anastomotic leakage (2.8% vs. 5.0%; P=0.55), recurrent laryngeal nerve paralysis (0.9% vs. 1.0%; P>0.99), and chylothorax (0.9% vs. 1.5%; P=0.66). Oncological adequacy was maintained, with similar total lymph node yields between the groups (33±11.1 vs. 32.1±12.2; P=0.53).ConclusionsSIMIE-RS provides superior perioperative outcomes as compared to MIMIE-PM, with significant reductions in pulmonary complications, enhanced functional recovery, improved pain control, and shortened hospital stays, as well as comparable surgical safety and oncological adequacy. Our findings indicate that SIMIE-RS is a viable innovation in esophageal cancer surgery that concentrates operative trauma while optimizing reconstruction pathways.

Minimally Invasive Esophagectomy for Esophageal Cancer: A 14-Year Experience of Over 1000 Consecutive Cases from a High-Volume Center in India

Post-esophagectomy hiatal hernia (PEHH) is a rare but potentially serious complication of esophagectomy, particularly following minimally invasive approaches. This study aims to evaluate the incidence, risk factors, diagnostic methods, and therapeutic strategies for PEHH through a systematic review and meta-analysis. MEDLINE, Scopus and Cochrane bibliographical databases were systematically searched according to PRISMA guidelines for studies concerning PEHH (last search: 22nd February 2025). A meta-analysis was conducted with pooled odds ratios (ORs) to assess potential risk factors. Thirty-four studies with 837 PEHH cases were included. The overall incidence of PEHH was 4.1%. Minimally invasive esophagectomy (MIE) was associated with an increased risk for PEHH (OR: 5.70, p-value < 0.001). Obesity (BMI > 25kg/m2) significantly reduced PEHH rates (OR 0.84, p-value < 0.001). Neoadjuvant chemoradiotherapy was also associated with increased PEHH incidence (OR: 3.53, p-value < 0.001). A minimally invasive surgical repair of PEHH was performed in 50.4% of cases. Postoperative morbidity rate was 31.7% and mortality rate was 2.1%. PEHH incidence is rising, with MIE approach and neoadjuvant therapy being possible risk factors. Surgical repair remains the standard for symptomatic cases, while an individualized approach is recommended for asymptomatic patients with consideration of long-term cancer prognosis.

BackgroundRecently, the minimally invasive transcervical esophagectomy (MICE) technique was introduced as a new approach for esophagectomy. The aim of this explorative study was to compare the effects of minimally invasive transthoracic esophagectomy (MIE), the most commonly used esophagectomy technique, versus MICE on postoperative immune function.MethodsFor this explorative cohort study, data regarding 42 F4S PREHAB trial participants (NL8699, International Clinical Trials Registry Platform) were analyzed. Immune function was assessed preoperatively and on postoperative day 1 (POD1) via plasma cytokines [interleukin (IL)-6, tumor necrosis factor (TNF), and IL-10], damage-associated molecular patterns (DAMPs) (S100A8/A9 and S100A12), and the Olink targeted proteomics inflammation panel. Ex vivo cytokine production was measured using whole blood stimulation with Escherichia coli lipopolysaccharides. Circulating C-reactive protein (CRP) concentrations (end of surgery until POD7) were analyzed in the F4S PREHAB cohort, supplemented with additional patients who underwent MICE or MIE in the same hospital.ResultsConcentrations of circulating cytokines and DAMPs, ex vivo cytokine production, and levels of additional inflammatory proteins on POD1 did not differ between groups (MIE, n=21; MICE, n=21). The dynamics of circulating CRP concentrations during the first week after surgery were also similar in the MICE (n=61) and MIE (n=66) groups.ConclusionsThis explorative study found no differences in postoperative inflammatory status between the two procedures. Limited statistical power and sample size warrant larger trials to further investigate potential differences in postoperative immune response and clinically relevant outcomes.

To assess the value of adding of a pyloroplasty procedure during the performance of minimally invasive esophagectomy (MIE) or robotically assisted MIE (RAMIE), we conducted a prospective, phase III randomized controlled trial (RCT)(NCT03740542). Many surgeons include pyloroplasty when performing esophagectomy, but few studies have provided level 1 evidence to support or refute this step especially in the era of MIE and RAMIE. An adaptive randomization trial design was utilized to maximize patients treated on more effective therapy and conversely minimize accrual to a less effective procedure. The trial was designed to proceed until one arm was established as superior or until a total of 140 patients had been treated and deemed evaluable for response. The primary endpoints of the study were pneumonia and/or anastomotic leak requiring surgery within 30 days of surgery. Over a 4-year period, 143 patients were randomized, and 134 patients were evaluable. The greater likelihood of success for pyloroplasty throughout the trial resulted in more patients randomized towards pyloroplasty (n= 90) vs. no pyloroplasty (n=44). Pneumonia or an anastomotic leak occurred in 16 of 90 (18%) patients in the pyloroplasty arm vs. 12 of 44 (27%) in the no-pyloroplasty arm. The stopping criteria were met when the posterior probability of pyloroplasty being superior reached 90%. The design of this trial led to early stopping because the short-term results indicated that outcomes in the pyloroplasty arm were superior to the no-pyloroplasty arm. This RCT provides evidence for short-term benefits of adding pyloroplasty to MIE or RAMIE. The long-term outcomes and quality of life measures continue to be monitored.

Robot-assisted minimally invasive esophagectomy (RAMIE) may enhance visualization and lymph-node dissection compared with conventional minimally invasive esophagectomy (cMIE), but comparative effectiveness remains uncertain. We performed a PRISMA-compliant systematic review and meta-analysis of randomized controlled trials and propensity-matched cohort studies comparing RAMIE with MIE (from 2013 to August 26th, 2025). PubMed, Cochrane Library, Embase, and Web of Science were searched. Continuous outcomes were pooled as mean differences (MD) and dichotomous outcomes as risk ratio (RR) using randomized-effects models; heterogeneity was assessed with I2. Risk of bias was evaluated with RoB-2 for trials and the Newcastle-Ottawa Scale for cohorts. Twenty-five studies (~ 8,900 patients; RAMIE ≈ 4,200; MIE ≈ 4,700) met eligibility criteria. Total operative time was longer with RAMIE (MD 38.91min, 95% CI 16.05-61.76; p = 0.0008; I²=97%), while thoracic operative time alone was not significantly different (MD 16.18min, 95% CI - 2.46 to 34.82; p = 0.09; I²=94%). Estimated blood loss was modestly lower with RAMIE (MD - 12.73 mL, 95% CI - 25.25 to - 0.21; p = 0.05; I²=86%). RAMIE achieved a higher total lymph node yield (MD 2.01 nodes, 95% CI 1.05-2.96; p < 0.001; I²=57%) and retrieved more left RLN lymph nodes (MD 0.60, 95% CI 0.13-1.08; p = 0.01), with no significant difference in right RLN nodes (MD 0.11, 95% CI - 0.02 to 0.24; p = 0.09; I² = 31%). In-hospital mortality (RR 0.76, 95% CI 0.42-1.39; p = 0.38; I²=0%) and 90-day mortality (RR 0.97, 95% CI 0.53-1.77; p = 0.91; I²=0%) were similar. Overall complications (RR 0.90, 95% CI 0.79-1.02; p = 0.09) and major complications (RR 0.80, 95% CI 0.63-1.01; p = 0.06) did not differ. Pulmonary complications trended lower (RR 0.88, 95% CI 0.76-1.02; p = 0.10), and recurrent laryngeal nerve palsy was borderline lower (RR 0.79, 95% CI 0.62-1.00; p = 0.05). Length of stay was shorter with RAMIE (MD - 1.28 days, 95% CI - 2.26 to - 0.34; p = 0.01; I²=84%), whereas ICU stay was longer (MD 2.68 days, 95% CI 0.51-4.84; p = 0.02; I²=98%). Publication bias signals for thoracic operative time and length of stay were driven by outlier on sensitivity analysis. RAMIE and cMIE are both safe. RAMIE involves a longer operative time but yields lower estimated blood loss, a higher total lymph nodes harvest-particularly along the left RLN- fewer pulmonary complications by trend, and a shorter length of stay, with no significant difference in anastomotic leak or early mortality. These results support patient-centered selection between RAMIE and cMIE, taking center experience and the learning curve into account. PROSPERO CRD420251134020.

Prolonged preoperative fasting has been reported to increase patient discomfort, induce insulin resistance, and lead to complications and delayed recovery. We introduced preoperative oral carbohydrate (CHO) loading, and this study aimed to evaluate the influence on the outcomes of esophageal cancer surgery. We evaluated 270 patients who underwent minimally invasive esophagectomy for esophageal cancer. Before implementation, patients fasted after the evening meal on the day before surgery and received glucose-electrolyte infusion. After implementation, patients received oral CHO loading up to three hours before surgery instead of infusion. We evaluated its impact on the incidence of perioperative complications, time to first defecation, length of hospital stay, and postoperative glycemic changes using interrupted time series analysis. There were 136 and 134 patients before and after implementation, respectively. No patient experienced aspiration during anesthesia induction. No significant changes were observed in the incidence of postoperative complications (coefficient 6.51, 95% confidence interval - 20.6 to 33.6) or length of stay (coefficient 1.34, 95% confidence interval - 4.75 to 7.42) after the implementation. Meanwhile, a significant reduction in time to first defecation was observed after implementation (coefficient - 0.73, 95% confidence interval - 1.42 to - 0.05). No significant differences in postoperative blood glucose levels were noted. Preoperative oral CHO loading for esophageal cancer surgery can be safely implemented without increasing postoperative complications, blood glucose levels, or length of hospital stay, and is associated with reduction in time to first defecation.

Background: Esophageal cancer ranks among the top ten most prevalent cancers worldwide and remains a significant contributor to cancer-related mortality. While surgery combined with neoadjuvant therapy stands as the cornerstone treatment, the evolution of surgical techniques towards minimally invasive procedures has shown promising results. Robotic Assisted Minimally Invasive Esophagectomy (RAMIE) emerges as a potential advancement, offering precise movements and a three-dimensional endoscopic view. Against this backdrop, clarifying whether a fully robotic approach provides measurable perioperative or early oncologic advantages over a hybrid technique is clinically relevant. Despite initial skepticism, studies comparing fully robotic and hybrid approaches for esophagectomy have been conducted to evaluate their feasibility and sustainability. Methods: A systematic review and meta-analysis were performed following PRISMA guidelines. Four retrospective studies comparing fully robotic and hybrid approaches were included, comprising 1540 patients. Results: Intraoperative outcomes favored the fully robotic approach, showing shorter operative times and reduced blood loss (MD = -41 min, p = 0.056, 95% CI: -83.202; 0.994 and MD = -48.762 mL, p = 0.040, 95% CI: -95.257; -2.266, respectively). Additionally, the fully robotic approach demonstrated advantages in terms of lymph node retrieval and shorter ICU and hospital stay (MD = -0.894, p < 0.0001, 95% CI: -1.224; -0.564, MD = -1.139 days, p < 0.0001, 95% CI: -1.313; -0.965 and MD = -3.264 days, p = 0.011, 95% CI: -5.767; -0.760, respectively). Conclusions: Although limitations exist, including the retrospective nature of the studies and limited sample size, the findings suggest that the fully robotic approach may offer superior outcomes compared to the hybrid approach for Ivor-Lewis esophagectomy. These results highlight the potential of robotics in enhancing safety and effectiveness in oesophageal cancer surgery, encouraging further consideration and adoption by surgeons.

Introduction: Identification of the thoracic duct (TD) is essential during esophageal surgery to reduce the risk of complications such as chylothorax. The clinical significance of the white plane, or Morosow's ligament-a consistent anatomical landmark along the esophagus-remains poorly defined. Methods: A total of 166 patients undergoing robot-assisted minimally invasive esophagectomy (RAMIE) were analyzed. Intraoperative visualization of the white plane was documented. Patient demographics, tumor characteristics, postoperative complications, management strategies, hospital length of stay, and overall survival were assessed. Complication severity was graded using the Clavien-Dindo classification. The Kaplan-Meier and multivariable Cox regression analyses were used to evaluate prognostic factors, including BMI, ASA score, pneumonia, pT status, pN status, neoadjuvant and adjuvant therapy, and white plane visualization. Results: The white plane was visualized in 154 patients (92.8%). Postoperative complications, management strategies, hospital length of stay, and 30-/90-day in-hospital mortality did not differ between groups with visualized and not visualized white planes. Median overall survival was significantly longer in patients with a visible white plane (43.1 vs. 13.1 months; p = 0.0079). The multivariable analysis identified ASA classification, pT stage, pN stage, and adjuvant therapy as independent predictors of overall survival, whereas lymph node stage and adjuvant therapy were independent predictors of recurrence-free survival. Conclusions: The white plane is a distinct intraoperative anatomical structure that can be visualized in most RAMIE procedures. Its identification may assist in TD recognition and provides a framework for describing mediastinal anatomy, but further studies are needed to determine its impact on surgical standardization and patient outcomes.