Dataset Information

Short-term clinical effects of robot-assisted esophagectomy with thoracic duct resection.

ABSTRACT:

Background

Whether extended robot-assisted esophagectomy with thoracic duct resection (RAE-TDR) has a favorable effect on esophageal cancer patients is not yet known. This study sought to analyze the safety and efficiency of RAE-TDR.

Methods

From January 2019 to July 2020, 73 thoracic duct (TD)-resected and 127 TD-preserved consecutive patients who received standard RAE McKeown surgery were enrolled in this study. The perioperative-related indicators of recurrence-free survival (RFS) and overall survival (OS) at 1-year were compared between the 2 groups.

Results

In relation to morbidity, the Clavien-Dindo (CD) classifications for grades greater than or equal to II-III were similar between the 2 groups (P>0.05). The number of retrieved total lymph nodes (LNs) and mediastinal nodes were significantly higher in the TD-resected group than in the TD-preserved group (total lymph nodes: 29.0±11.1 vs. 25.1±8.5, P=0.006; mediastinal nodes: 19.5±8.0 vs. 16.1±5.5, P=0.002). Additionally, more metastatic TD-related LNs were harvested in cT3-4 patients (2.3±3.7 vs. 1.7±2.8; P=0.21). The rates of LN recurrence and local recurrence were similar between the 2 groups (LN recurrence: 6.8% vs. 7.1%, P>0.99; local recurrence: 1.4% vs. 2.4%, P>0.99). The OS and RFS at 1-year were equivalent regardless of the TD procedure at each stage (P>0.05). However, the rate of hematogenous metastasis in the TD-resected group was significantly elevated (17.8% vs. 7.9%; P=0.034).

Conclusions

RAE-TDR may help to improve total and metastatic LN harvest, especially in patients with advanced esophageal squamous cell carcinoma (ESCC) without increasing the intra- and post-operative adverse events. However, RAE-TDR did not lead to a decrease in the local recurrence rate within the short-term follow-up period. Whether the increase in distant metastasis rate in the TD-resected group was associated with relevant immune system damage is unclear. Thus, nonselective RAE-TDR is not routinely recommended.

SUBMITTER: Li C

PROVIDER: S-EPMC10007922 | biostudies-literature | 2023 Feb

REPOSITORIES: biostudies-literature

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Publications

Short-term clinical effects of robot-assisted esophagectomy with thoracic duct resection.

Li Chunguang C Li Bin B Yang Yang Y Li Zhigang Z

Journal of gastrointestinal oncology 20230221 1

<h4>Background</h4>Whether extended robot-assisted esophagectomy with thoracic duct resection (RAE-TDR) has a favorable effect on esophageal cancer patients is not yet known. This study sought to analyze the safety and efficiency of RAE-TDR.<h4>Methods</h4>From January 2019 to July 2020, 73 thoracic duct (TD)-resected and 127 TD-preserved consecutive patients who received standard RAE McKeown surgery were enrolled in this study. The perioperative-related indicators of recurrence-free survival (R ...[more]

PMID: 36915429

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Project description: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.

Project description:Background Adequate pain control after open esophagectomy is associated with reduced complications, earlier recovery and higher patient satisfaction. While further developing surgical procedures like robot-assisted minimally invasive esophagectomy (RAMIE) it is relevant to adapt postoperative pain management. The primary question of this observational survey was whether one of the two standard treatments, thoracic epidural analgesia (TEA) or intravenous patient-controlled analgesia (PCA), is superior for pain control after RAMIE as the optimal pain management for these patients still remains unclear. Use of additional analgesics, changes in forced expiratory volume in 1 s (FEV1), postoperative complications and duration of intensive care and hospital stay were also analyzed. Methods This prospective observational pilot study analyzed 50 patients undergoing RAMIE (postoperative PCA with piritramide or TEA using bupivacaine; each n = 25). Patient reported pain using the numeric rating scale score and differences in FEV1 using a micro spirometer were measured at postoperative day 1, 3 and 7. Additional data of secondary endpoints were collected from patient charts. Results Key demographics, comorbidity, clinical and operative variables were equivalently distributed. Patients receiving TEA had lower pain scores and a longer-lasting pain relief. Moreover, TEA was an independent predictive variable for reduced length of hospital stay (HR -3.560 (95% CI: −6.838 to −0.282), p = 0.034). Conclusions Although RAMIE leads to reduced surgical trauma, a less invasive pain therapy with PCA appears to be inferior compared to TEA in case of sufficient postoperative analgesia and length of hospital stay. According to the results of this observational pilot study analgesia with TEA provided better and longer-lasting pain relief compared to PCA. Further randomized controlled trials should be conducted to evaluate the optimal postoperative analgesic treatment for RAMIE.

Project description:BackgroundIn Asia, esophageal squamous cell carcinoma (ESCC) accounts for more than 90% of esophageal cancer cases and can be treated with minimally invasive esophagectomy (MIE); however, MIE has certain technical limitations in resecting lymph nodes. The advantages of robot-assisted minimally invasive esophagectomy (RAMIE) surgery, such as the high-definition three-dimensional (3D) vision and the presence of the EndoWrist, facilitates movement in challenging anatomical regions. However, few studies have compared the postoperative outcomes between RAMIE with MIE for the lymph node dissection of patients with ESCC.MethodsWe identified 285 patients with ESCC who underwent surgical resection between January 2019 and April 2023. Of these patients, 270 met the screening criteria and were enrolled in our study. These patients were then divided into two groups according to the thoracic approach: MIE (n=168) or RAMIE cohort (n=102). The aim of this study was to investigate the possible advantages in terms of postoperative outcomes of RAMIE over MIE for thoracic lymph node dissection.ResultsMost patients were male (97.4%). According to the pathological-stage of esophageal cancer, 5 (1.9%), 99 (37.1%), 72 (27.0%), 82 (30.7%), and 9 (3.4%) patients were pathological-stage 0, I, II, III, and IV, respectively. The number of regional lymph node resections in the RAMIE cohort was significantly higher than that in the MIE group for the following regions: the left tracheobronchial lymph nodes (106tbL) (P<0.001), paratracheal lymph nodes [106pre] (P=0.011), the sub-longitudinal lymph nodes [107] (P<0.001), the left main bronchial lymph nodes [109L] (P<0.001), the right main bronchial lymph nodes [109R] (P<0.001), the sub-thoracic periesophageal lymph nodes [110] (P=0.004), and the supradiaphragmatic lymph nodes [111] (P<0.001). By comparing MIE cohort with RAMIE cohort, the transthoracic approach with RAMIE yielded a greater total number of thoracic lymph nodes dissected [MIE: mean 20.82, standard deviation (SD) 9.45; RAMIE: mean 26.07, SD 9.28; P<0.001] and a greater total number of lymph node groups that underwent thoracic lymph node dissection (MIE: mean 5.28, SD 1.94; RAMIE: mean 7.29, SD 1.77; P<0.001).ConclusionsOur study shows that RAMIE may be more effective than MIE in terms of the number thoracic lymph nodes dissected and the extent of dissection. Moreover, RAMIE may be not associated with additional surgical complications.

Dataset Information

Short-term clinical effects of robot-assisted esophagectomy with thoracic duct resection.

Background

Methods

Results

Conclusions

Publications

Short-term clinical effects of robot-assisted esophagectomy with thoracic duct resection.

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