International Society for Minimally Invasive Cardiothoracic Surgery

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Oncologic Outcomes After Robotic Thoracic Approach Versus Video-assisted Thoracic Approach During An Esophagectomy
Anupama Singh1, Ben Grobman1, Hillary Heiling2, Emanuele Mazzola2, Rachel Leo1, Rafael Barcelos1, Miles McAllister1, Fatemehsadat Pezeshkian1, Matthew Pommerening1, Matthew Rochefort1, Scott J. Swanson1, Michael T. Jaklitsch1, Raphael Bueno1, Jon O. Wee1
1Brigham and Women's Hospital, Boston, MA, USA, 2Dana-Farber Cancer Institute, Boston, MA, USA

Background: Comparison of oncologic outcomes between the video-assisted (VATS) vs. robot-assisted (RATS) esophagectomy is limited. Our primary objective was to compare disease-free survival (DFS) and overall survival (OS) between RATS vs. VATS thoracic approach during an esophagectomy. Methods: We reviewed a prospectively maintained institutional database to identify patients who underwent esophagectomy after neoadjuvant chemoradiation from 01/2013-09/2022. Patients were grouped into two categories by thoracic approach: RATS or VATS. Patients with pathologic stage IV were excluded. Propensity score weighted analysis was used to balance gender, BMI, and histology. Weighted Cox-proportional hazards regression was used to evaluate the impact of thoracic approach on DFS and OS after adjusting for covariates including margin positivity, pathological nodal status, and total number of lymph nodes (LN). Weighted modified Poisson regressions and weighted linear regressions were used to identify associations with dichotomous and continuous outcomes, respectively. Results: Of 652 patients included, 443 were Ivor Lewis and 209 were 3-hole esophagectomies. There were 107 RATS and 545 VATS. After matching, there were no significant differences between approaches regarding demographics, histology, pathologic nodal status, margin positivity or lymphovascular invasion. Using RATS for the thoracic portion resulted in an average increase of 3.14 LN sampled (95% CI: 1.71-4.58, p < 0.001) compared to VATS. In total, 71 patients experienced locoregional recurrence, 11 (15.5%) after RATS. After adjusting for covariates, DFS (HR: 1.27 [95% CI: 0.92-1.76], p=0.15) and OS (HR 1.32 [0.95-1.83], p=0.10) did not differ between the two approaches (Figure 1). Compared to VATS, RATS was not associated with higher rates of adverse events (RR 1.04 [0.85-1.27], p=0.70), readmissions (RR 0.78, [0.47, 1.28], p=0.32) or RTOR (RR 0.71, [0.31-1.61], p=0.41). RATS was associated with shorter LoS (average decrease -1.42 days, [-2.48 - -0.37], p=0.008). Average LoS in the RATS group was 9.9 days versus 11.4 days in the VATS group. Conclusions: Although robotic thoracic approach during an esophagectomy is associated with an increased number of LN sampled compared to video-assisted approach, there is no difference in oncologic outcomes between these techniques.

Figure 1. Adjusted disease-free (1A) and overall survival (1B) curves of robotic vs. video-assisted thoracic approach during an esophagectomy.

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