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Comparative outcomes of minimally invasive and robotic-assisted esophagectomy

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Kenneth Meredith
Kenneth Meredith
Kenneth Meredith
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Paige Blinn at Florida State University
Paige Blinn
Taylor Maramara at Orlando Health
Taylor Maramara
Caitlin Takahashi at East Carolina University
Caitlin Takahashi
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Abstract

Objective Minimally invasive esophagectomy (MIE) has demonstrated superior outcomes compared to open approaches. The myriad of techniques has precluded the recommendation of a standard approach. The addition of robotics to esophageal resection has potential benefits. We sought to examine the outcomes with MIE to include robotics. Methods Utilizing a prospective esophagectomy database, we identified patients who underwent (MIE) Ivor Lewis via thoracoscopic/laparoscopic (TL), transhiatal (TH), or robotic-assisted Ivor Lewis (RAIL). Patient demographics, tumor characteristics, and complications were analyzed via ANOVA, χ², and Fisher exact where appropriate. Results We identified 302 patients who underwent MIE: TL 95 (31.5%), TH 63 (20.8%), and RAIL 144 (47.7%) with a mean age of 65 ± 9.6. The length of operation was longer in the RAIL: TL (299 ± 87), TH (231 ± 65), RAIL (409 ± 104 min), p < 0.001. However, the EBL was lower in the patients undergoing transthoracic approaches (RAIL + TL): TL (189 ± 188 ml), TH (242 ± 380 ml), RAIL (155 ± 107 ml), p = 0.03. Conversion to open was also lower in these patients: TL 7 (7.4%), TH 8 (12.7%), RAIL 0, p < 0.001. The R0 resection rate and lymph node (LN) harvest also favored the RAIL cohort: TL 86 (93.5%), TH 60 (96.8%), and RAIL 144 (100%), p = 0.01; LN: TL 14 ± 7, TH 9 ± 6, and RAIL 20 ± 9, p < 0.001. The overall morbidity was lower in MIE patients that underwent a transthoracic approach vs. transhiatal: TL 29 (30.5%), TH 39 (61.9%), RAIL 34 (23.6%), p < 0.001. Conclusions Patients undergoing MIE via thoracoscopic/laparoscopic and robotic transthoracic approaches demonstrated lower EBL, morbidity, and conversion to open compared to the transhiatal approach. Additionally the oncologic outcomes measured by R0 resections and LN harvest also favored the patients who underwent a transthoracic approach.
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Vol:.(1234567890)
Surgical Endoscopy (2020) 34:814–820
https://doi.org/10.1007/s00464-019-06834-7
1 3
Comparative outcomes ofminimally invasive androbotic‑assisted
esophagectomy
KennethMeredith1,3,5· PaigeBlinn1· TaylorMaramara1· CaitlinTakahashi2· JamieHuston3· RaviShridhar4
Received: 21 December 2018 / Accepted: 15 May 2019 / Published online: 10 June 2019
© Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
Objective Minimally invasive esophagectomy (MIE) has demonstrated superior outcomes compared to open approaches.
The myriad of techniques has precluded the recommendation of a standard approach. The addition of robotics to esophageal
resection has potential benefits. We sought to examine the outcomes with MIE to include robotics.
Methods Utilizing a prospective esophagectomy database, we identified patients who underwent (MIE) Ivor Lewis via
thoracoscopic/laparoscopic (TL), transhiatal (TH), or robotic-assisted Ivor Lewis (RAIL). Patient demographics, tumor
characteristics, and complications were analyzed via ANOVA, χ2, and Fisher exact where appropriate.
Results We identified 302 patients who underwent MIE: TL 95 (31.5%), TH 63 (20.8%), and RAIL 144 (47.7%) with a
mean age of 65 ± 9.6. The length of operation was longer in the RAIL: TL (299 ± 87), TH (231 ± 65), RAIL (409 ± 104min),
p < 0.001. However, the EBL was lower in the patients undergoing transthoracic approaches (RAIL + TL): TL (189 ± 188ml),
TH (242 ± 380ml), RAIL (155 ± 107ml), p = 0.03. Conversion to open was also lower in these patients: TL 7 (7.4%), TH
8 (12.7%), RAIL 0, p < 0.001. The R0 resection rate and lymph node (LN) harvest also favored the RAIL cohort: TL 86
(93.5%), TH 60 (96.8%), and RAIL 144 (100%), p = 0.01; LN: TL 14 ± 7, TH 9 ± 6, and RAIL 20 ± 9, p < 0.001. The overall
morbidity was lower in MIE patients that underwent a transthoracic approach vs. transhiatal: TL 29 (30.5%), TH 39 (61.9%),
RAIL 34 (23.6%), p < 0.001.
Conclusions Patients undergoing MIE via thoracoscopic/laparoscopic and robotic transthoracic approaches demonstrated
lower EBL, morbidity, and conversion to open compared to the transhiatal approach. Additionally the oncologic outcomes
measured by R0 resections and LN harvest also favored the patients who underwent a transthoracic approach.
Keywords Transhiatal esophagectomy· Transthoracic esophagectomy· Robotic esophagectomy
Esophageal cancer is ranked as the eighth most common and
sixth most deadly cancer worldwide [1, 2]. The incidence
of esophageal adenocarcinoma has continued to increase
over the last several decades. It is estimated that there will
be 17,290 new cases of esophageal cancer diagnosed, with
15,850 dying from the disease in the United States in 2018
[3]. The average age at the time of diagnosis also continues
to rise with a peak incidence between 75 and 79years of
age. Surgical resection often in combination with neoad-
juvant chemoradiation (NCR) remains the primary method
for treatment of patients with locally advanced esophageal
cancer [4]. Esophagectomy is associated with a high mor-
bidity and mortality, and the long-term survival similarly
demonstrates poor outcomes despite improvements in multi-
modality care over the last several decades with less than
25% of patients surviving for 5years [5, 6, 7].
Esophagectomy is often performed via an open or mini-
mally invasive transabdominal (TH, transhiatal), transtho-
racic (Ivor Lewis), or three-incision (TF, Mckeown) tech-
nique [4, 8]. Minimally invasive Ivor Lewis esophagectomy
is a transthoracic esophagectomy that consists of a combina-
tion of laparoscopic and thoracoscopic (TL) resection of the
and Other Interventional Te
chniques
* Kenneth Meredith
Dr.Kenneth-Meredith@smh.com; kensurg@hotmail.com
1 Florida State University College ofMedicine, Tallahassee,
USA
2 Naval Medical Center Portsmouth, Portsmouth, USA
3 Sarasota Memorial Institute forCancer Care, Sarasota, USA
4 Florida Hospital Cancer Institute, Orlando, USA
5 Gastrointestinal Oncology, Sarasota Memorial Institute
forCancer Care, 1950 Arlington Suite 101, Sarasota,
FL34239, USA
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... 34 Pneumonia is a common cause of morbidity after esophagectomy and poor pain control is a major causative factor. 42,52 Smaller incisions required in robotic esophagectomy and the reduced nerve injury result in less pain after surgery, better respiratory effort and reduced risk of pneumonia. Tsunoda et al. demonstrated a lower rate of pulmonary complications (18%, p = 0.006) among patients who underwent robot-assisted esophagectomy compared with conventional minimally invasive esophagectomy (44%). ...
... 42 Notably, Meredith et al. reported no significant difference in the incidence of pneumonia between patients undergoing open, robotic or conventional minimally invasive esophagectomy. 52 In comparison, three studies reported an incidence of postoperative pneumonia of >30%, despite all patients undergoing laparoscopic and robotic phases, suggesting a multifactorial aetiology for postoperative pneumonia. 33,54,55 Twenty studies reported total inpatient LoS of < 10 days; none of these studies used an open approach for the thoracic or abdominal phases. ...
... 33,54,55 Twenty studies reported total inpatient LoS of < 10 days; none of these studies used an open approach for the thoracic or abdominal phases. 25,41,43,44,52,[56][57][58][59][60][61][62][63][64][65][66][67][68][69] In comparison, 27 studies reported total LoS > 14 days, of which six used an open approach in either the abdominal or thoracic pha ses. 5,24,25,33,42,45,46,55,[70][71][72][73][74][75][76][77][78][79][80][81][82][83][84][85] This indicates the robotic and conventional minimally invasive approaches are associated with shorter LoS, however clinical trials are required to validate this. 1, 26,27 Factors contributing to reduced LoS include less postoperative pain and nausea, earlier introduction of oral intake, and mobilisation. ...
Is Robotic Surgery the Future for Resectable Esophageal Cancer?: A Systematic Literature Review of Oncological and Clinical Outcomes
Article
Full-text available
  • Mar 2024
Background Radical esophagectomy for resectable esophageal cancer is a major surgical intervention, associated with considerable postoperative morbidity. The introduction of robotic surgical platforms in esophagectomy may enhance advantages of minimally invasive surgery enabled by laparoscopy and thoracoscopy, including reduced postoperative pain and pulmonary complications. This systematic review aims to assess the clinical and oncological benefits of robot-assisted esophagectomy. Methods A systematic literature search of the MEDLINE (PubMed), Embase and Cochrane databases was performed for studies published up to 1 August 2023. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols and was registered in the PROSPERO database (CRD42022370983). Clinical and oncological outcomes data were extracted following full-text review of eligible studies. Results A total of 113 studies ( n = 14,701 patients, n = 2455 female) were included. The majority of the studies were retrospective in nature ( n = 89, 79%), and cohort studies were the most common type of study design ( n = 88, 79%). The median number of patients per study was 54. Sixty-three studies reported using a robotic surgical platform for both the abdominal and thoracic phases of the procedure. The weighted mean incidence of postoperative pneumonia was 11%, anastomotic leak 10%, total length of hospitalisation 15.2 days, and a resection margin clear of the tumour was achieved in 95% of cases. Conclusions There are numerous reported advantages of robot-assisted surgery for resectable esophageal cancer. A correlation between procedural volume and improvements in outcomes with robotic esophagectomy has also been identified. Multicentre comparative clinical studies are essential to identify the true objective benefit on outcomes compared with conventional surgical approaches before robotic surgery is accepted as standard of practice.
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... This outcome showed no statistically significant difference between RAMIE and cMIE. Three of the included studies had a higher rate of conversion to open procedure [40,42,43]. These were explained by all the advantages that the robotic system has to offer in attaining proficiency in the procedures. ...
Short-term outcomes of robot-assisted versus conventional minimally invasive esophagectomy for esophageal cancer: a systematic review and meta-analysis of 18,187 patients
Article
Full-text available
  • Mar 2024
The role of robotic surgery in the curative-intent treatment of esophageal cancer patients is yet to be defined. To compare short-term outcomes between conventional minimally invasive (cMIE) and robot-assisted minimally invasive esophagectomy (RAMIE) in esophageal cancer patients. PubMed, Web of Science and Cochrane Library were systematically searched. The included studies compared short-term outcomes between cMIE and RAMIE. Individual risk of bias was calculated using the MINORS and RoB2 scales. There were no statistically significant differences between RAMIE and cMIE regarding conversion to open procedure, mean number of harvested lymph nodes in the mediastinum, abdomen and along the right recurrent laryngeal nerve (RLN), 30- and 90-day mortality rates, chyle leakage, RLN palsy as well as cardiac and infectious complication rates. Estimated blood loss (MD − 71.78 mL, p < 0.00001), total number of harvested lymph nodes (MD 2.18 nodes, p < 0.0001) and along the left RLN (MD 0.73 nodes, p = 0.03), pulmonary complications (RR 0.70, p = 0.001) and length of hospital stay (MD − 3.03 days, p < 0.0001) are outcomes that favored RAMIE. A significantly shorter operating time (MD 29.01 min, p = 0.004) and a lower rate of anastomotic leakage (RR 1.23, p = 0.0005) were seen in cMIE. RAMIE has indicated to be a safe and feasible alternative to cMIE, with a tendency towards superiority in blood loss, lymph node yield, pulmonary complications and length of hospital stay. There was significant heterogeneity among studies for some of the outcomes measured. Further studies are necessary to confirm these results and overcome current limitations.
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... Among the 57 patients in the present study who underwent the robot-assisted minimally invasive IL procedure, the mean number of harvested LNs was 21±8, the mean number of positive LNs was 3.75±5.18, and the mean postoperative hospital stay was 10.7±2.4 days (about 11 days), similar to a previous report (25). For closure of the common lumen, layered sutures between the mucosal layers or muscular layers of the esophagus and stomach are recommended (9). ...
Clinical outcomes of the robot-assisted Ivor Lewis procedure for adenocarcinoma of the esophagogastric junction with semi-instrument overlap intrathoracic anastomosis
Article
Full-text available
  • Jan 2024
Background The main difficulty of minimally invasive Ivor Lewis (IL) procedure for adenocarcinoma of the esophagogastric junction (AEGJ) is the intrathoracic esophagogastric anastomosis (IEA). We aimed to assess the safety and feasibility of the IL procedure with the da Vinci surgical system for treatment of AEGJ with semi-mechanical intrathoracic IEA. Methods The cohort included 72 patients with AEGJ who received treatment at the Department of Minimally Invasive Esophagus Surgery of the Tianjin Medical University Cancer Institute and Hospital from August 2020 to March 2023. Of these 72 patients, 17 received neoadjuvant chemo-immunotherapy. The robot-assisted minimally invasive IL procedure was performed using a linear stapler for overlap side-to-side intrathoracic anastomosis and the stapler defect was closed with double full-layer continuous sutures by robotic hand-sewn (semi-mechanical) IEA. Results Of the 72 AEGJ patients, 2 were converted to exploration, 7 were converted to laparotomy and thoracotomy for circular-stapled intrathoracic anastomosis, and 6 were converted to thoracotomy for circular-stapled anastomosis, which included 2 cases of extensive pleural adhesion and 4 cases of overlap anastomosis failure, whereas 57 underwent the robot-assisted minimally invasive IL procedure with semi-mechanical IEA. Among the 9 patients converted to laparotomy, the laparotomy rate was closely related to the Siewert classification (P<0.005) and preoperative use of neoadjuvant therapy (P<0.05). Among the 57 patients who underwent the robot-assisted minimally invasive IL procedure with semi-mechanical IEA, there were 2 cases of anastomotic leakages (2/57, 3.5%), no case of anastomotic stricture, 5 cases of postoperative pneumonia (5/57, 8.77%), 2 cases of intensive care unit admission (2/57, 3.5%), and 1 case of readmission within 30 days (1/57, 1.75%). None of the patients died within 30 days after surgery. Conclusions The robot-assisted minimally invasive IL procedure with semi-mechanical IEA is both safe and feasible for AEGJ. However, caution is advised for patients with Siewert type III AEGJ and those who have already received preoperative neoadjuvant therapy.
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... Despite early criticism for the MIE and RAMIE, the efficiency of thoracic oncology surgeons has improved significantly over the past decade, resulting in safe and feasible surgical treatment of esophageal cancer when compared to OE [32,[47][48][49] . There have been multiple studies that have evaluated the short-term outcomes of MIE and RAMIE compared to conventional OE. 13, P < 0.001) [5] . ...
A comparative review of minimally invasive approaches to esophagectomy: technical considerations, variations, and outcomes
Article
Full-text available
  • Oct 2023
Esophageal cancer continues to rise as a public health issue, and esophagectomy remains a mainstay therapy for the disease. Surgical approaches to esophagectomy have evolved over the past few decades with the advent of laparoscopic, thoracoscopic, and robotic technologies. The aim of this review is to identify original articles and perform a comprehensive literature search to provide updates on surgical approaches and technical considerations for esophagectomy. Articles describing the surgical technique specific to robotic-assisted minimally invasive esophagectomy (RAMIE) were reviewed and included. Technical considerations reviewed were comprised of patient positioning, optimal trocar placement, dissection, indocyanine green use, kocherization, pyloric interventions, anastomotic techniques, jejunostomy tube placement, and gastric ischemic conditioning, discussing relevant outcomes for each consideration and approach. Clinical outcomes were also evaluated by comparing RAMIE to open esophagectomy and minimally invasive esophagectomy. Outcomes reviewed included lymph node harvest, intra-operative blood loss, operative times, 30-day readmission, mortality, length of stay, pulmonary complications, recurrent laryngeal nerve injury, anastomotic leak, long-term survival, and disease-free survival.
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... Robotic TTE was used in this patient population to further assess the robotic system's capability to achieve tumor clearance, measured via R0 resection rates, whilst preserving the azygos vein and reducing anastomotic leakage rates. Robot-assisted MAS is associated with higher rates of R0 resection compared with conventional MAS 14,29 and open surgery 4 . We provide further evidence to show that R0 resection rates using robot-assisted surgery in patients requiring TTE are comparable to other surgical methods, thus demonstrating the effectiveness of this surgical system. ...
Feasibility of transthoracic esophagectomy with a next-generation surgical robot
Article
Full-text available
  • Oct 2022
Robot-assisted minimal access surgery (MAS), compared with conventional MAS, has shown a number of benefits across several therapeutic indications but its use for transthoracic esophagectomy (TTE) requires further evaluation. Here, we report the first-in-human series of major esophageal resections performed using a next-generation tele-operated robotic surgical system in a single center. Robot-assisted TTE was performed using the Versius Surgical System by a single surgeon to assess the robotic system’s ability to achieve tumor clearance (measured by R0 resection rates) whilst reducing anastomotic leakage rates. Intra- and post-operative outcomes such as median operative time, length of hospitalization, intra-operative blood loss, and the number of complications were also assessed. Fifty-seven patients underwent robot-assisted TTE between August 2019 and June 2021. All procedures were completed successfully with no unplanned conversions to alternative surgical methods. Estimated blood loss was minimal, and no adverse events, complications or deaths were reported. Our experience with the Versius Surgical System demonstrates its safe adoption and implementation for TTE.
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... the rate of diagnosis in the younger population has been increasing recently. 2 The global 5-year survival rate has increased to approximately 40%. 3 With this increase in survival rate, there is also a growing need for multidisciplinary strategies to improve the quality of life (QOL) of survivors of esophageal cancer. ...
Effects of Multimodal Inpatient Rehabilitation vs Conventional Pulmonary Rehabilitation on Physical Recovery After Esophageal Cancer Surgery
Article
  • Jun 2022
  • ARCH PHYS MED REHAB
Objective To determine the effects of multimodal rehabilitation initiated immediately after esophageal cancer surgery on physical recovery compared to conventional pulmonary rehabilitation. Design Retrospective study. Setting Private quaternary care hospital. Participants Fifty-nine inpatients who participated in either conventional pulmonary rehabilitation (n = 30) or in multimodal rehabilitation (n = 29) after esophageal cancer surgery were included. Interventions Both groups performed pulmonary exercises, including deep breathing, chest expansion, inspiratory muscle training, coughing, and manual vibration. In the conventional pulmonary rehabilitation group, light-intensity mat exercise, stretching, and walking were performed. The multimodal rehabilitation group performed resistance exercises and moderate-to-high-intensity aerobic interval exercises using a bicycle. Main Outcome Measures The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire C30 (EORTC QLQ-C30), pain, 6-minute walk test (6MWT), 30-second chair stand test, and grip strengths were assessed before and after the rehabilitation programs. Results Symptom scales of pain, dyspnea, and insomnia in the EORTC QLQ C-30 as well as 6MWT improved significantly after each program (p < 0.05). 6MWT (73.1 ± 52.6 vs. 28.4 ± 14.3, p < 0.001, d = 1.15), 30-second chair stand test (3.5 ± 3.9 vs. 0.35 ± 2.0, p < 0.001, d = 1.06), and left grip strength (1.2 ± 1.3 vs. 0.0 ± 1.5, p = 0.002, d = 0.42) improved significantly in the multimodal rehabilitation group compared with the pulmonary rehabilitation group. While right grip strength also showed more improvement for those undergoing the multimodal program, the mean strength difference was not clinically meaningful. Conclusions A multimodal inpatient rehabilitation program instituted early after esophageal cancer surgery improved endurance for walking as measured by the 6MWT as well as the 30-second chair stand test, more than conventional pulmonary rehabilitation.
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Robotic Minimally Invasive Esophagectomy
Article
  • Feb 2023
  • Thorac Surg Clin
Robotic minimally invasive esophagectomy can be safely performed by adhering to key technical principles. Careful development of the gastric conduit with attention to blood supply and conduit orientation is critical. During thoracic dissection, capnothorax can distort the proximity of key mediastinal structures. In particular, care must be taken to avoid damage to the left mainstem bronchus during subcarinal nodal dissection. Robotic approach allows for an oncologically sound procedure and early mobilization of patients postoperatively, thus optimizing short and long-term outcomes.
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Robot-assisted Ivor Lewis Esophagectomy (RAILE): A review of surgical techniques and clinical outcomes
Article
Full-text available
  • Nov 2022
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.
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Transthoracic Esophagectomy: Hand-sewn Versus Side-to-side Linear-stapled Versus Circular-stapled Anastomosis: A Systematic Review and Meta-analysis
Article
Full-text available
  • Mar 2022
Background: Three anastomotic techniques are mostly used to create an esophagogastric anastomosis in a transthoracic esophagectomy: hand-sewn (HS), side-to-side linear-stapled (SSLS), and circular-stapled (CS). The aim of this study was to compare surgical outcomes after HS, SSLS, and CS intrathoracic esophagogastric anastomosis. Materials and methods: A systematic review using the MEDLINE database was performed to identify original articles analyzing outcomes after HS, SSLS, and CS esophagogastric anastomosis. The main outcome was an anastomotic leakage rate. Secondary outcomes included overall morbidity, major morbidity, and mortality. A meta-analysis of proportions and linear regression models were used to assess the effect of each anastomotic technique on the different outcomes. Results: A total of 101 studies comprising 12,595 patients were included; 8835 (70.1%) with CS, 2532 (20.1%) with HS, and 1228 (9.8%) with SSLS anastomosis. Anastomotic leak occurred in 10% [95% confidence interval (CI), 6%-15%], 9% (95% CI, 6%-13%), and 6% (95% CI, 5%-7%) of patients after HS, SSLS, and CS anastomosis, respectively. Risk of anastomotic leakage was significantly higher with HS anastomosis (odds ratio=1.73, 95% CI: 1.47-2.03, P<0.0001) and SSLS (odds ratio=1.68, 95% CI: 1.36-2.08, P<0.0001), as compared with CS. Overall morbidity (HS: 52% vs. SLSS: 39% vs. CS: 35%) and major morbidity (HS: 33% vs. CS: 19%) rates were significantly lower with CS anastomosis. Mortality rate was 4% (95% CI, 3%-6%), 2% (95% CI, 2%-3%), and 3% (95% CI, 3%-4%) after HS, SSLS, and CS anastomosis, respectively. Conclusion: HS and SSLS intrathoracic esophagogastric anastomoses are associated with significantly higher rates of an anastomotic leak than CS anastomosis.
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Open vs. Hybrid vs. Totally Minimally Invasive Ivor Lewis Esophagectomy: Systematic Review and Meta-analysis
Article
Full-text available
  • Jan 2022
  • J THORAC CARDIOV SUR
Background Hybrid and minimally invasive approaches have emerged as less invasive alternatives to open Ivor Lewis esophagectomy. The aim of this study was to compare surgical outcomes between open (OE), hybrid (HE) and totally minimally invasive esophagectomy (TMIE). Methods A systematic literature search was performed to analyze outcomes after OE, HE and TMIE with intrathoracic anastomosis. Main outcomes included anastomotic leak rate, overall morbidity and 30-day mortality, and. A meta-analysis of proportions was used to assess the effect of each approach on different outcomes. Results A total of 130 studies comprising 16,053 patients were included for analysis; 8,081 (50.3%) underwent OE, 1,524 (9.5%) HE, and 6,448 (40.2%) TMIE. The risk of anastomotic leak was lower after OE (OR 0.71, 95% CI 0.62–0.81, p<0.0001). Overall morbidity rate was 45% (95% CI, 38-52%) after OE, 40% (95% CI, 25-59%) after HE, and 37% (95% CI, 32-43%) after TMIE. Risk estimation showed higher odds of postoperative mortality after OE (OR 2.22, 95% CI 1.76–2.81, p<0.0001) and HE (OR 1.93, 95% CI 1.32–2.81, p<0.001), as compared to TMIE. Median length of hospital stay (LOS) was 14.1 (8-28), 12.5 (8-18) and 11.9 (7-30) days after OE, HE and TMIE, respectively (p=0.003). Conclusion HE and TMIE are associated with lower rates of overall morbidity, reduced postoperative mortality, and shorter LOS, as compared to OE. TMIE is associated with lower mortality and shorter LOS than HE. Further efforts are needed to widely embrace TMIE in a safely manner.
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Epidemiology of esophageal cancer
Article
Full-text available
  • Sep 2013
  • WORLD J GASTROENTERO
Esophageal cancer (EsC) is one of the least studied and deadliest cancers worldwide because of its extremely aggressive nature and poor survival rate. It ranks sixth among all cancers in mortality. In retrospective studies of EsC, smoking, hot tea drinking, red meat consumption, poor oral health, low intake of fresh fruit and vegetables, and low socioeconomic status have been associated with a higher risk of esophageal squamous cell carcinoma. Barrett's esophagus is clearly recognized as a risk factor for EsC, and dysplasia remains the only factor useful for identifying patients at increased risk, for the development of esophageal adenocarcinoma in clinical practice. Here, we investigated the epidemiologic patterns and causes of EsC. Using population based cancer data from the Surveillance, Epidemiology and End Results Program of the United States; we generated the most up-to-date stage distribution and 5-year relative survival by stage at diagnosis for 1998-2009. Special note should be given to the fact that esophageal cancer, mainly adenocarcinoma, is one of the very few cancers that is contributing to increasing death rates (20%) among males in the United States. To further explore the mechanism of development of EsC will hopefully decrease the incidence of EsC and improve outcomes.
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Su1536 Defining the Learning Curve for Robotic-Assisted Esophagogastrectomy
Article
Full-text available
  • May 2013
  • J GASTROINTEST SURG
Introduction: The expansion of robotic-assisted surgery is occurring quickly, though little is generally known about the "learning curve" for the technology with utilization for complex esophageal procedures. The purpose of this study is to define the learning curve for robotic-assisted esophagogastrectomy with respect to operative time, conversion rates, and patient safety. Methods: We have prospectively followed all patients undergoing robotic-assisted esophagogastrectomy and compared operations performed at our institutions by a single surgeon in successive cohorts of 10 patients. Our measures of proficiency included: operative times, conversion rates, and complications. Statistical analyses were undertaken utilizing Spearman regression analysis and Mann-Whitney U test. Significance was accepted with 95 % confidence. Results: Fifty-two patients (41 male: 11 female) of mean age 66.2 ± 8.8 years underwent robotic-assisted esophagogastrectomies for malignant esophageal disease. Neoadjuvant chemoradiation was administered to 30 (61 %) patients. A significant reduction in operative times (p <0.005) following completion of 20 procedures was identified (514 ± 106 vs. 397 ± 71.9). No conversions to open thoracotomy were required. Complication rates were low and not significantly different between any 10-patient cohort; however, no complications occurred in the final 10-patient cohort. There were no in-hospital mortalities. Conclusions: For surgeons proficient in performing minimally-invasive esophagogastrectomies, the learning curve for a robotic-assisted procedure appears to begin near proficiency after 20 cases. Operative complications and conversions were infrequent and unchanged across successive 10-patient cohorts.
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Minimally Invasive Surgery for Esophageal Cancer: Review of the Literature and Institutional Experience
Article
Full-text available
  • Apr 2013
Esophageal cancer represents a major public health problem in the world. Several minimally invasive esophagectomy (MIE) techniques have been described and represent a safe alternative for the surgical management of esophageal cancer in selected centers with high volume and surgeons experienced in minimally invasive procedures. The authors reviewed the most recent and largest studies published in the medical literature that reported the outcomes for MIE techniques. In larger series, MIE has proven to be equivalent in postoperative morbidity and mortality to the open esophagectomy. However, MIE has been associated with less blood loss, reduced postoperative pain, decreased time in the intensive care unit, and shortened length of hospital stay compared with the conventional open approaches. Despite limited data, no significant difference in survival stage for stage has been observed between open esophagectomy and MIE. The myriad of MIE techniques complicates the debate for defining the optimal surgical approach for the treatment of esophageal cancer. Randomized controlled trials comparing MIE with conventional open esophagectomy are needed to clarify the ideal procedure with the lowest postoperative morbidity, best quality of life after surgery, and long-term survival.
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Esophageal Cancer Surgery: Spontaneous Centralization in the US Contributed to Reduce Mortality Without Causing Health Disparities
Article
  • Jan 2018
Background: Improvement in mortality has been shown for esophagectomies performed at high-volume centers. Objective: This study aimed to determine if centralization of esophageal cancer surgery occurred in the US, and to establish its impact on postoperative mortality. In addition, we aimed to analyze the relationship between regionalization of cancer care and health disparities. Methods: A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000-2014. Adult patients (≥ 18 years of age) diagnosed with esophageal cancer and who underwent esophagectomy were included. Yearly hospital volume was categorized as low (< 5 procedures), intermediate (5-20 procedures), and high (> 20 procedures). Multivariable analyses on the potential effect of hospital volume on patient outcomes were performed, and the yearly rate of esophagectomies was estimated using Poisson regression. Results: A total of 5235 patients were included. Esophagectomy at low- [odds ratio (OR) 2.17] and intermediate-volume (OR 1.62) hospitals, compared with high-volume hospitals, was associated with a significant increase in mortality. The percentage of esophagectomies performed at high-volume centers significantly increased during the study period (29.2-68.5%; p < 0.0001). The trend towards high-volume hospitals was different among the different US regions: South (7.7-54.3%), West (15.0-67.6%), Midwest (37.3-67.7%), and Northeast (55.8-86.8%) [p < 0.0001]. Overall, the mortality rate of esophagectomy dropped from 10.0 to 3.5% (p = 0.006), with non-White race, public insurance, and low household income patients also showing a significant reduction in mortality. Conclusions: A spontaneous centralization for esophageal cancer surgery occurred in the US. This process was associated with a decrease in the mortality rate, without contributing to health disparities.
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Cancer Statistics, 2017
Article
  • Dec 2016
Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data were collected by the National Center for Health Statistics. In 2017, 1,688,780 new cancer cases and 600,920 cancer deaths are projected to occur in the United States. For all sites combined, the cancer incidence rate is 20% higher in men than in women, while the cancer death rate is 40% higher. However, sex disparities vary by cancer type. For example, thyroid cancer incidence rates are 3-fold higher in women than in men (21 vs 7 per 100,000 population), despite equivalent death rates (0.5 per 100,000 population), largely reflecting sex differences in the "epidemic of diagnosis." Over the past decade of available data, the overall cancer incidence rate (2004-2013) was stable in women and declined by approximately 2% annually in men, while the cancer death rate (2005-2014) declined by about 1.5% annually in both men and women. From 1991 to 2014, the overall cancer death rate dropped 25%, translating to approximately 2,143,200 fewer cancer deaths than would have been expected if death rates had remained at their peak. Although the cancer death rate was 15% higher in blacks than in whites in 2014, increasing access to care as a result of the Patient Protection and Affordable Care Act may expedite the narrowing racial gap; from 2010 to 2015, the proportion of blacks who were uninsured halved, from 21% to 11%, as it did for Hispanics (31% to 16%). Gains in coverage for traditionally underserved Americans will facilitate the broader application of existing cancer control knowledge across every segment of the population. CA Cancer J Clin 2017. © 2017 American Cancer Society.
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Minimally invasive surgery for endometrial cancer
Article
  • Aug 2015
  • CURR OPIN OBSTET GYN
To critically appraise the pertinent literature on traditional laparoscopy and robotically assisted laparoscopy for the treatment of endometrial cancer. Multiple retrospective and prospective studies on traditional laparoscopy and retrospective studies on robotically assisted laparoscopy for the treatment of uterine cancers have shown reduced blood loss, shorter length of hospital stay and decreased incidence and severity of postoperative surgical complications compared with laparotomy. Minimally invasive techniques maintain equivalent oncologic results with regard to the number of dissected lymph nodes and overall and disease-free survival rates.Compared with traditional laparoscopy, robotic surgery has a lower rate of conversion to laparotomy, lower blood loss and presents significant ergonomic advantages for the surgeon facilitating execution of complex oncologic procedures. Minimally invasive techniques are particularly advantageous in obese patients, reducing perioperative and postoperative abdominal wound complications. A thorough review of the literature indicates that minimally invasive approach has a number of established advantages over laparotomy that makes it the surgical treatment option of choice in endometrial carcinoma patients.
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Comparison of Minimally Invasive Esophagectomy With Transthoracic and Transhiatal Esophagectomy
Article
  • Aug 2000
  • ARCH SURG-CHICAGO
Hypothesis Minimally invasive esophagectomy can be performed as safely as conventional esophagectomy and has distinct perioperative outcome advantages.Design A retrospective comparison of 3 methods of esophagectomy: minimally invasive, transthoracic, and blunt transhiatal.Setting University medical center.Patients Eighteen consecutive patients underwent combined thoracoscopic and laparoscopic esophagectomy from October 9, 1998, through January 19, 2000. These patients were compared with 16 patients who underwent transthoracic esophagectomy and 20 patients who underwent blunt transhiatal esophagectomy from June 1, 1993, through August 5, 1998.Main Outcome Measures Operative time, amount of blood loss, number of operative transfusions, length of intensive care and hospital stays, complications, and mortality.Results Patients who had minimally invasive esophagectomy had shorter operative times, less blood loss, fewer transfusions, and shortened intensive care unit and hospital courses than patients who underwent transthoracic or blunt transhiatal esophagectomy. There was no significant difference in the incidence of anastomotic leak or respiratory complications among the 3 groups.Conclusion Minimally invasive esophagectomy is safe and provides clinical advantages compared with transthoracic and blunt transhiatal esophagectomy.
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Outcomes After Minimally Invasive Esophagectomy Review of Over 1000 Patients
Article
  • Jun 2012
  • ANN SURG
Esophagectomy is a complex operation and is associated with significant morbidity and mortality. In an attempt to lower morbidity, we have adopted a minimally invasive approach to esophagectomy. Our primary objective was to evaluate the outcomes of minimally invasive esophagectomy (MIE) in a large group of patients. Our secondary objective was to compare the modified McKeown minimally invasive approach (videothoracoscopic surgery, laparoscopy, neck anastomosis [MIE-neck]) with our current approach, a modified Ivor Lewis approach (laparoscopy, videothoracoscopic surgery, chest anastomosis [MIE-chest]). We reviewed 1033 consecutive patients undergoing MIE. Elective operation was performed on 1011 patients; 22 patients with nonelective operations were excluded. Patients were stratified by surgical approach and perioperative outcomes analyzed. The primary endpoint studied was 30-day mortality. The MIE-neck was performed in 481 (48%) and MIE-Ivor Lewis in 530 (52%). Patients undergoing MIE-Ivor Lewis were operated in the current era. The median number of lymph nodes resected was 21. The operative mortality was 1.68%. Median length of stay (8 days) and ICU stay (2 days) were similar between the 2 approaches. Mortality rate was 0.9%, and recurrent nerve injury was less frequent in the Ivor Lewis MIE group (P < 0.001). MIE in our center resulted in acceptable lymph node resection, postoperative outcomes, and low mortality using either an MIE-neck or an MIE-chest approach. The MIE Ivor Lewis approach was associated with reduced recurrent laryngeal nerve injury and mortality of 0.9% and is now our preferred approach. Minimally invasive esophagectomy can be performed safely, with good results in an experienced center.
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