Robot-assisted Ivor-Lewis Esophagectomy Research Articles

Totally minimally invasive laparoscopic robot-assisted Ivor Lewis esophagectomy: improved technique and outcomes over 200 cases.

Surgical resection of esophageal and gastroesophageal junction cancers is a very complex procedure with step learning curve. New technologies have made minimally invasive surgery possible, but challenges still remain for wide spread adoption of these techniques. This article aims to describe the outcomes and salient technical points of a totally minimally invasive, laparoscopic, robot-assisted Ivor Lewis esophagectomy (LRAMIE). Retrospective observational cohort study performed at a specialty cancer center using a prospectively maintained institutional database. Patients undergoing LRAMIE (laparoscopic abdomen, robotic chest) from 2014-2023 were included. Patients undergoing transhiatal and three-field esophagectomy were excluded. Operative and postoperative outcomes were compared over the study period to identify potential associations between outcomes over time. Two-hundred patients were identified who underwent LRAMIE. Median age was 65 years and most were male (87.5%). The open conversion rate was 1% (n=2), which occurred within the first 30 cases. Operative time and blood loss were improved at the 60-case mark (P<0.001). Anastomotic stricture rate improved after 50 cases, and leak rate improved after 80 cases. Postoperative length of stay improved at both 50 and 100 cases with a median LOS of 6 days after 100 cases. Rate of postoperative pneumonia, 30- and 90-day mortality were reduced after 100 cases, although not statistically significant for mortality due to too few events. Totally minimally invasive Ivor Lewis esophagectomy at a high-volume center is a safe procedure. Operative outcomes improved significantly after 50-80 cases, followed by improvement in anastomotic results and postoperative outcomes, with corresponding excellent oncologic outcomes.

Comparison of Clinical Efficacy Between Da Vinci Robot-Assisted Ivor Lewis Esophagectomy and McKeown Esophagectomy for Middle and Lower Thoracic Esophageal Cancer: A Multicenter Propensity Score-Matched Study.

We compared the perioperative efficacy and safety of da Vinci robot-assisted Ivor Lewis esophagectomy and McKeown esophagectomy for middle and lower thoracic esophageal cancer. A retrospective case-control study method was used. A total of 181 patients with esophageal cancer admitted to three medical centers in China from February 2018 to October 2022 were collected and divided into two groups according to surgical method: da Vinci robot-assisted thoracic surgery (RATS) Ivor Lewis esophagectomy (Ivor Lewis group) and RATS McKeown esophagectomy (McKeown group), respectively. Propensity score matching (PSM) analysis was used to reduce selection bias caused by confounding factors. The perioperative indicators of the two groups were compared and analyzed. There was a statistically significant difference in age and tumor location between the Ivor Lewis group and the McKeown group. After PSM, the above factors were no longer statistically significant. There were 80 patients in each group after PSM. In terms of operative time (P = 0.005), anastomotic leakage (P = 0.029), and pulmonary infection (P = 0.035), the Ivor Lewis group has significant advantages; in terms of the number of lymph nodes dissected around the recurrent laryngeal nerve (P = 0.010), the McKeown group has significant advantages. Both RATS Ivor Lewis esophagectomy and McKeown esophagectomy are safe and effective for treatment of middle and lower thoracic esophageal cancer. Ivor Lewis has advantages in operative time, anastomotic leakage, and pulmonary infection, while McKeown has advantage in lymph node dissection around the recurrent laryngeal nerve.

The evolution of anastomotic techniques in robot-assisted Ivor Lewis esophagectomy

Radical esophagectomy is the cornerstone in the treatment of esophageal cancer combined with perioperative therapies, whereas patients diagnosed at an early stage may be candidates for endoscopic resection. Minimally invasive procedures aim to improve the postoperative complications and reduce overall morbidity. The short and long-term results of the incorporation of robot-assisted esophagectomy in specialised centres worldwide have been encouraging. The Ivor Lewis technique has become the preferable approach, reaching up to 61% of the minimally invasive reconstructions in the Western World; however, the percentage of anastomotic leaks remains problematic. Throughout the last decade, a few modifications of the anastomotic technique have been proposed in an effort to improve the surgical results of the robot-assisted approach. This review presents the evolving robotic techniques of performing the esophagogastric anastomosis. An overview of the available approaches will be discussed with a focus on the intrathoracic anastomosis.

Robot-assisted Ivor Lewis Esophagectomy (RAILE): A review of surgical techniques and clinical outcomes.

In the past 20 years, robotic system has gradually found a place in esophagectomy which is a demanding procedure in the deep and narrow thoracic cavity containing crucial functional structures. Ivor Lewis esophagectomy (ILE) is a mainstream surgery type for esophagectomy and is widely accepted for its capability in lymphadenectomy and relatively mitigated trauma. As a minimally invasive technique, robot-assisted Ivor Lewis esophagectomy (RAILE) has been frequently compared with the video-assisted procedure and the traditional open procedure. However, high-quality evidence elucidating the advantages and drawbacks of RAILE is still lacking. In this article, we will review the surgical techniques, both short and long-term outcomes, the learning curve, and explicate the current progress and clinical efficacy of RAILE.

Learning curve for robot-assisted Ivor Lewis esophagectomy.

This study aimed to demonstrate the learning curve of robot-assisted minimally invasive esophagectomy (RAMIE). A retrospective analysis of the first 124 consecutive patients who underwent RAMIE with intrathoracic anastomosis (Ivor Lewis) by a single surgeon between May 2015 and August 2020 was performed. An risk-adjusted cumulative sum (RA-CUSUM) analysis was applied to generate a learning curve of RAMIE considering the major complication rate, which reflected the technical proficiency. The overall 30-day morbidity rate was 38.7%, while the major complication rate was 25.8%. The learning curve was divided into two phases based on the RA-CUSUM analysis: phase I, the initial learning phase (cases 1-51) and phase II, the proficiency phase (cases 52-124). As we compared the proficiency phase with the initial learning phase, significantly decreased trends were observed in relation to the major complication rate (37.3% vs. 18.7%, P = 0.017), total operation time (330.9 ± 55.6 vs. 267.3 ± 39.1minutes, P < 0.001), and length of hospitalization (10 [IQR, 9-14] days vs. 9 [IQR, 8-11] days, P = 0.034). In conclusion, the learning curve of RAMIE consisted of two phases, and at least 51 cases were required to gain technical proficiency.

Long-term outcomes after robotic-assisted Ivor Lewis esophagectomy

Robotic assistance has gained acceptance in thoracic procedures, including esophagectomy. There is a paucity of data regarding long-term outcomes for robotic esophagectomy. We previously reported our initial series of robot-assisted Ivor Lewis (RAIL) esophagectomy. We report long-term outcomes to assess the efficacy of the procedure. We performed a retrospective review of 112 consecutive patients who underwent a RAIL. Patient demographics, diagnosis, pathology, operative characteristics, post-operative complications, and long-term outcomes were documented. Descriptive statistical analysis was performed for all the variables. Primary endpoints were mortality and disease-free survival. Overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. Of the 112 patients, 106 had a diagnosis of cancer, with adenocarcinoma the dominant histology (87.5%). Of these 106 patients, 81 (76.4%) received neo-adjuvant chemoradiation. The 30-, 60-, and 90-day mortality was 1 (0.9%), 3 (2.7%), and 4 (3.6%), respectively. There were 9 anastomotic leaks (8%) and 18 (16.1%) patients had a stricture requiring dilation. All-patient OS at 1, 3, and 5years was 81.4%, 60.5%, and 51.0%, respectively. For cancer patients, the 1-, 3-, and 5-year OS was 81.3%, 59.2%, and 49.4%, respectively, and the DFS was 75.3%, 42.3%, and 44.0%. We have shown that long-term outcomes after RAIL esophagectomy are similar to other non-robotic esophagectomies. Given the potential advantages of robotic assistance, our results are crucial to demonstrate that RAIL does not result in inferior outcomes.

Learning Curve for Robot-Assisted Ivor Lewis Esophagectomy: Results of 100 Consecutive Cases

Learning Curve for Robot-Assisted Ivor Lewis Esophagectomy: Results of 100 Consecutive Cases

Recurrent laryngeal nerve monitoring during totally robot-assisted Ivor Lewis esophagectomy

PurposeThe robot-assisted approach for Ivor Lewis esophagectomy offers an enlarged, three-dimensional overview of the intraoperative situs. The vagal nerve (VN) can easily be detected, preserved, and intentionally resected below the separation point of the recurrent laryngeal nerve (RLN). However, postoperative vocal cord paresis can result from vagal or RLN injury during radical lymph node dissection, presenting a challenge to the operating surgeon.MethodsFrom May to August 2019, 10 cases of robot-assisted minimally invasive esophagectomy (RAMIE) with extended 2-field lymphadenectomy, performed at the University Medical Center Mainz, were included in a prospective cohort study. Bilateral intermittent intraoperative nerve monitoring (IONM) of the RLN and VN was performed, including pre- and postoperative laryngoscopy assessment.ResultsReliable mean signals of the right VN (2.57 mV/4.50 ms) and the RLN (left 1.24 mV/3.71 ms, right 0.85 mV/3.56 ms) were obtained. IONM facilitated the identification of the exact height of separation of the right RLN from the VN. There were no cases of permanent postoperative vocal paresis. Median lymph node count from the paratracheal stations was 5 lymph nodes.ConclusionIONM was feasible during RAMIE. The intraoperative identification of the RLN location contributed to the accuracy of lymph node dissection of the paratracheal lymph node stations. RLN damage and subsequent postoperative vocal cord paresis can potentially be prevented by IONM.

Robotic Side‐to‐Side and End‐to‐Side Stapled Esophagogastric Anastomosis of Ivor Lewis Esophagectomy for Cancer

Both linear-stapled side-to-side esophagogastric anastomosis (LSEA) and circular-stapled end-to-side esophagogastric anastomosis (CEEA) are frequently used following esophagectomy. The aims of the present study were to review our experience of robotic intrathoracic alimentary tract reconstruction and to compare the short-term surgical outcomes of LSEA and CEEA in robotic Ivor Lewis esophagectomy. A prospectively collected dataset from 79 consecutive patients who underwent robot-assisted Ivor Lewis esophagectomy from February 2016 to December 2018 was retrospectively analyzed. Two groups (LSEA and CEEA) were classified according to the anastomotic mode. Demographic data, intraoperative characteristics and short-term surgical outcomes were compared between the two groups. Two patients were converted to laparotomy. The remaining 77 patients (68 males and 9 females, mean age of 61.7years) were successfully treated with completely robotic Ivor Lewis esophagectomy. According to the anastomotic procedure performed, 35 patients were categorized into the LSEA group and 42 patients were categorized into the CEEA group. The mean anastomotic time in the LSEA group was longer than that in the CEEA group (63.0 ± 9.0 vs. 44.2 ± 8.5min, p < 0.001). No significant difference was detected in anastomotic complications, including leakage (8.6% with LSEA and 4.8% with CEEA, p = 0.83) and postoperative dysphagia (5.7% with LSEA and 16.7% with CEEA, p = 0.26). No statistical difference was observed for the other surgical outcomes. There was no incidence of in-hospital mortality and 30-day mortality in both groups. In robotic Ivor Lewis esophagectomy, both LSEA and CEEA were feasible and safe to be performed and surgeons can select either LSEA or CEEA based on their own technical expertise.

Intrathoracic side-to-side esophagogastrostomy with a linear stapler and barbed suture in robot-assisted Ivor Lewis esophagectomy.

BackgroundThe side‐to‐side anastomosis was considered a promising approach to create an intrathoracic esophagogastrostomy in the minimally invasive esophagectomy, with advantages over the side‐to‐end anastomosis with aspects of no need for additional mini‐thoracotomy and lower occurrence of stenosis. The hand‐sewing anterior aspect of the anastomosis is technically challenging in the thoracoscopic Ivor Lewis esophagectomy. Here we introduced our initial experience to facilitate this approach by using the surgical robot and barbed suture.MethodsA retrospective study of all patients underwent robot‐assisted Ivor Lewis esophagectomy with side‐to‐side esophagogastrostomy from February 2016 to September 2018 was performed. The technical details are described in this paper.ResultsA total of 37 patients (35 male and 2 female, median age of 62.7 years) were successfully treated with completely robot‐assisted Ivor Lewis esophagectomy. The median total surgical time was 340 minutes including 65 minutes to perform the anastomosis. Median estimated blood loss was 120 mL and the length of hospital stay was 10 days. There was no 90‐day mortality. Three patients suffered anastomotic leakage (8.1%,3/37), who were successfully treated without reoperation.ConclusionOur initial results imply that it is technically feasible to perform intrathoracic gastroesophageal anastomosis by taking advantage of a robotic system and knotless suturing.

Robotic-assisted Ivor-Lewis esophagectomy

Esophagectomy is the core treatment modality for operable esophageal cancer. For middle and lower third esophageal carcinoma, Ivor Lewis two stage esophagectomy is increasingly performed worldwide. In recent years, minimally invasive esophagectomy (MIE) has been widely applied, which has the superiority over open esophagectomy in terms of postoperative morbidity and mortality. The robotic surgical system provides a three-dimensional, high definition view, and improved stability and flexibility for operation, which unveiled a new era of MIE. Robot-assisted Ivor-Lewis esophagectomy (RAILE) has been suggested as a safe and feasible procedure for the treatment of operable middle and distal esophageal cancer. This review focuses on the perioperative and oncological outcomes of RAILE based on available evidence.

Robot-assisted Ivor-Lewis esophagectomy dissection of lymph nodes along left recurrent laryngeal nerve

Robot-assisted Ivor-Lewis esophagectomy dissection of lymph nodes along left recurrent laryngeal nerve

Robot-assisted Ivor-Lewis esophagectomy dissection of lymph nodes along right recurrent laryngeal nerve

Robot-assisted Ivor-Lewis esophagectomy dissection of lymph nodes along right recurrent laryngeal nerve

ASO Author Reflections: The Role of Robot-Assisted Ivor Lewis Esophagectomy for Esophageal Cancer.

ASO Author Reflections: The Role of Robot-Assisted Ivor Lewis Esophagectomy for Esophageal Cancer.

Modified Intrathoracic Esophagogastrostomy with Minimally Invasive Robot-Assisted Ivor-Lewis Esophagectomy for Cancer

Background: Intrathoracic esophagogastrostomy plays an important role in minimally invasive Ivor-Lewis esophagectomy for cancer. Intrathoracic anastomosis with robot-assisted Ivor-Lewis esophagectomy (RAILE) includes hand-sewn and circular stapler methods, which remain technically challenging. In this study, we modified the techniques for intrathoracic anastomosis at RAILE, in order to simplify the complex procedures. Methods: “Side-insertion” technique was used for anvil placement and purse string suture for intrathoracic anastomosis at RAILE. Medical records for consecutive patients who had undergone robot-assisted minimally invasive Ivor-Lewis esophagectomy for cancer between January 2015 and June 2018 were analyzed. Results: A total of consecutive 31 patients were enrolled. There was no conversion to open thoracotomy in this cohort. Mean operation duration in the robotic group was 387.4 ± 68.2 min. Median estimated blood loss was 110 mL (range 50–400 mL). Two patients (6.5%) had postoperative anastomotic leak. No postoperative reoperation was needed and there were no mortality. Six patients (19.4%) had anastomotic stricture and 2 patients of them needed endoscopic dilation. Conclusion: RAILE is safe and feasible. Our modified procedure highlighting the “side-insertion” method may simplify the process of intrathoracic anvil placement and purse string suture for anastomosis at RAILE.

PS01.224: MODIFIED INTRATHORACIC ESOPHAGOGASTROSTOMY AT MINIMALLY INVASIVE ROBOT-ASSISTED IVOR-LEWIS ESOPHAGECTOMY FOR CANCER

Abstract Background The intrathoracic esophagogastrostomy played important role in minimally invasive Ivor-Lewis esophagectomy for cancer. The methods of intrathoracic esophagogastric anastomosis at robot-assisted Ivor-Lewis esophagectomy mostly included hand-sewn, and circular stapler (anvil placement via OrVil system or transthoracically), which were still technically challenging. In this study, we modified the techniques of intrathoracic esophagogastric anastomosis at robot-assisted Ivor-Lewis esophagectomy for cancer, in order to seek to simplify this complicated intrathoracic procedure. Then retrospective comparison between robotic and thoracoscopic cohorts was conducted. Methods We modified techniques focused on the ‘side-insertion’ anvil placement and purse string suture of intrathoracic robot-assisted esophagogastric anastomosis. The consecutive records of patients who underwent minimally invasive Ivor-Lewis esophagectomy for cancer via robot-assistant and thoracoscopic procedures in our department between January 2015 and November 2017 were retrospectively analyzed. Results Totally 47 patients were enrolled including 20 patients (male: 17, female: 3) in robot-assisted group and 27 patients (male: 21, female: 6) in thoracoscopic group. There was no conversion to open thoracotomy in both two groups. Mean operation duration of robotic group was 412.5 ± 63.5 min, significantly higher than 363.0 ± 53.3 min in thoracoscopic group (P = 0.006). Estimated blood loss in robotic group was less than that in thoracoscopic group (107.5 ± 63.5ml vs. 188.9 ± 94.3ml, respectively, P = 0.002). One patient (5.0%) in robotic group and two patients(7.4%) in thoracoscopic group had anastomotic leak. No postoperative reoperation or mortality (in-hospital or within 30 days after surgery) occurred in both groups. Conclusion Robot-assisted Ivor-Lewis esophagectomy was safe and feasible. Our modified procedure highlighting the ‘side-insertion’ method could simplify the process of intrathoracic anvil placement and purse string suture for the robot-assisted esophagogastric anastomosis. Robot-assisted Ivor-Lewis esophagectomy was nearly equivalent to thoracoscopic Ivor-Lewis esophagectomy at short-term outcomes, except higher operation time and less blood loss. Disclosure All authors have declared no conflicts of interest.

Early Experience of Robot-Assisted Esophagectomy With Circular End-to-End Stapled Anastomosis

Surgical resection is a critical element in the treatment of esophageal cancer. Esophagectomy is technically challenging and is associated with high morbidity and mortality rates. Efforts to reduce these rates have spurred the adoption of minimally invasive techniques. This study describes a single-institution experience of robot-assisted esophagectomy with circular end-to-end stapled anastomosis. Between December 2013 and April 2015, a series of consecutive patients underwent robot-assisted Ivor Lewis esophagectomy with circular end-to-end anastomosis (RAILE-EEA) at a tertiary care center with curative intent. We retrospectively reviewed their electronic medical records using real-time prospectively collected data. The operative and postoperative outcomes were recorded. Twenty patients underwent RAILE-EEA during the study period. The abdominal mobilization was performed laparoscopically, and the thoracic portion was robotic. The median total operative time was 455 minutes (range, 318-765 minutes), the 90-day operative mortality was 0%, and morbidity was present in 11 of 20 patients (55%). Atrial fibrillation was the most common event and was observed in 3 patients (15%). There were no anastomotic leaks. The median estimated blood loss was 275 mL, and the conversion rate was 0%. Complete (R0) resection was achieved in all cases. The mean number of lymph nodes was 23.2 (± 2.26). The median follow-up time was 330 days (range, 108-600 days), and the overall 1-year survival was 84%. RAILE-EEA in our institution suggests a safe, effective, and reproducible alternative with satisfactory postoperative outcomes for the treatment of esophageal cancer. It provided good local control, adequate lymphadenectomy, low morbidity, and low 90-day operative mortality.