International Society for Minimally Invasive Cardiothoracic Surgery

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Improved Short-term Gains, Yet Comparable Long-term Prognosis: Robot-assisted Minimally Invasive Esophagectomy For Upper Esophageal Cancer
Yuxin Yang, Chao Jiang, Dr., Zhichao Liu, Dr., Bin Li, Dr., Chunguang Li, Dr., Yang Yang, Dr., Zhigang Li, Prof.
Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai, China

BACKGROUND:Robot-assisted minimally invasive esophagectomy (RAMIE) constitutes an increasing proportion of esophagectomies. Initial findings from the randomized RAMIE trial have demonstrated enhanced technical capabilities when compared to conventional minimally invasive esophagectomy (MIE). However, its superiority in challenging esophagectomy cases remains controversial. This study aims to assess both short-term and long-term outcomes of RAMIE in contrast to the MIE approach for patients diagnosed with upper esophageal cancer.
METHODS:Between November 2015 and December 2022, patients who underwent minimally invasive esophagectomy were identified from a prospectively maintained database. A 1:1 propensity match (RAMIE: MIE) was conducted for multiple clinical covariates to address selection bias. The primary endpoint of this study is overall survival, while secondary endpoints included postoperative morbidity, lymph node yield, readmission rate, as well as 30-day and 90-day mortality rates.
RESULTS:A total of 316 patients, 158 in each arm were included in this study. RAMIE was associated with shorter operative duration (270[interquartile, IQR 242-313] vs 302[248-343] mins, P<0.001) and a higher number of lymph node yield (26[17-33] vs 21[15-30], P<0.001) when compared to MIE. With regard to upper mediastinal lymphadenectomy, RAMIE demonstrated superiority than MIE cohort, showing a higher achievement rate of both Left- (88.6% vs 70.9%) and Right-RLN (94.9% vs 85.4%) lymph nodes (all P<0.05). No significant difference was identified in terms of any postoperative complications (46.2% vs 50.6%, P=0.431) or major complications [C-D ≥III] (11.4% vs 12.7%, P=0.729), but a significant reduction of postoperative pneumonia was associated with RAMIE approach (7.6% vs 14.6%, P=0.047). In short-term outcomes, there was no significant difference in 30-day (0.0% vs 0.6%) or 90-day mortality (1.3% vs 1.3%) between both cohorts. Furthermore, both cohorts demonstrated similar long-term prognosis, with 5-year survival rate being 51.9% in RAMIE and 53.9% in MIE cohort (all P>0.05). CONCLUSIONS:In the era of minimally invasive surgery, RAMIE has demonstrated improved short-term outcomes with comparable mortality and morbidity, even in the well-known challenging context of upper esophageal cancer. The robotic technique enables a more radical lymphadenectomy, however there was no discernible difference in survival so far. Long-term results from RAMIE trail still warranted to elucidate this phenomenon.


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