Format for safe introduction of robotic esophagectomy

Abstract

The aim of this study is to review the current literature on the learning curve for robotic-assisted minimally invasive esophagectomy (RAMIE) and explore strategies for introducing and implementing RAMIE. A literature search of electronic databases (Pubmed and Science Direct) was conducted using multiple combinations and synonyms of the keywords “esophageal cancer”, “robotic esophagectomy”, “RAMIE”, and “learning curve” up to March 31, 2023. In total, eighteen studies were included. Fourteen studies reported on surgeons with experience in minimally invasive surgery. Seven studies reported on surgeons with prior robotic experience for benign diseases or experience as observant or assistant in robotic surgery or experience on cadaveric robotic training. Four studies reported on a specific training pathway. The learning curve was mostly analyzed using the cumulative sum control chart (CUSUM). The most commonly used measured variables were the total operation time, the thoracic and abdominal console time, the lymph node yield, and vocal cord palsy rates. Τhe learning curve plateaus for the total operative time, the vocal cord palsy rates, and the lymph node yield varied between 20-80, 15-80, and 18-73 cases, respectively. At present, several centers are increasingly adopting RAMIE for esophageal cancer. Education about the learning curve of RAMIE is crucial for the training pathway in order to safely introduce RAMIE in centers without pre-existing robotic esophagectomy experience.

Keywords

Robotic esophagectomy / RAMIE / esophageal cancer / learning curve

References

[1] Morgan E,Rumgay H.The global landscape of esophageal squamous cell carcinoma and esophageal adenocarcinoma incidence and mortality in 2020 and projections to 2040: new estimates from GLOBOCAN 2020.Gastroenterology2022;163:649-58.e2

[2] van Hagen P,van Lanschot JJ.Preoperative chemoradiotherapy for esophageal or junctional cancer.N Engl J Med2012;366:2074-84

[3] Lorenzen S,Homann N,Jäger E.Feasibility of perioperative chemotherapy with infusional 5-FU, leucovorin, and oxaliplatin with (FLOT) or without (FLO) docetaxel in elderly patients with locally advanced esophagogastric cancer.Br J Cancer2013;108:519-26 PMCID:PMC3593547

[4] Levy RM,Shende M.Laparoscopic and thoracoscopic esophagectomy.Adv Surg2010;44:101-16

[5] Kato H.Treatments for esophageal cancer: a review.Gen Thorac Cardiovasc Surg2013;61:330-5

[6] van Boxel GI, Kingma BF, Voskens FJ, Ruurda JP, van Hillegersberg R. Robotic-assisted minimally invasive esophagectomy: past, present and future.J Thorac Dis2020;12:54-62 PMCID:PMC7061186

[7] van der Sluis PC,van der Horst S.Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer, a randomized controlled trial (ROBOT trial).Trials2012;13:230 PMCID:PMC3564860

[8] de Groot EM,Kingma BF.Robot-assisted minimally invasive thoracolaparoscopic esophagectomy versus open esophagectomy: long-term follow-up of a randomized clinical trial.Dis Esophagus2020;33:doaa079

[9] Biere SS,Maas KW.Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial.Lancet2012;379:1887-92

[10] Maas KW,van Berge Henegouwen MI.Quality of life and late complications after minimally invasive compared to open esophagectomy: results of a randomized trial.World J Surg2015;39:1986-93 PMCID:PMC4496501

[11] Paireder M,Kristo I.Morbidity in open versus minimally invasive hybrid esophagectomy (MIOMIE): long-term results of a randomized controlled clinical study.Eur Surg2018;50:249-55 PMCID:PMC6267426

[12] Yang Y,Yi J.Robot-assisted versus conventional minimally invasive esophagectomy for resectable esophageal squamous cell carcinoma: early results of a multicenter randomized controlled trial: the RAMIE trial.Ann Surg2022;275:646-53

[13] Seesing MFJ,Goense L.A propensity score matched analysis of open versus minimally invasive transthoracic esophagectomy in the Netherlands.Ann Surg2017;266:839-46

[14] Kernstine KH,Karimi M.The robotic, 2-stage, 3-field esophagolymphadenectomy.J Thorac Cardiovasc Surg2004;127:1847-9

[15] Giulianotti PC,Angelini M.Robotics in general surgery: personal experience in a large community hospital.Arch Surg2003;138:777-84

[16] Han Y,Zhang W.Learning curve for robot-assisted Ivor Lewis esophagectomy.Dis Esophagus2022;35:doab026

[17] Tagkalos E,Berlth F.Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus minimally invasive esophagectomy for resectable esophageal adenocarcinoma, a randomized controlled trial (ROBOT-2 trial).BMC Cancer2021;21:1060 PMCID:PMC8474742

[18] Sun HB,Liu XB.Perioperative outcomes and learning curve of robot-assisted McKeown esophagectomy.J Gastrointest Surg2023;27:17-26

[19] Hsieh MJ,Wen YW,Chiu CH.Impact of prior thoracoscopic experience on the learning curve of robotic McKeown esophagectomy: a multidimensional analysis.Surg Endosc2022;36:5635-43

[20] Park SY,Kang DR.Learning curve for robotic esophagectomy and dissection of bilateral recurrent laryngeal nerve nodes for esophageal cancer.Dis Esophagus2017;30:1-9

[21] Kingma BF,Van der Sluis PC.A structured training pathway to implement robot-assisted minimally invasive esophagectomy: the learning curve results from a high-volume center.Dis Esophagus2020;33:doaa047

[22] Sarkaria IS,Grosser R.Attaining proficiency in robotic-assisted minimally invasive esophagectomy while maximizing safety during procedure development.Innovations2016;11:268-73 PMCID:PMC5427663

[23] van der Sluis PC, Ruurda JP, van der Horst S, Goense L, van Hillegersberg R. Learning curve for robot-assisted minimally invasive thoracoscopic esophagectomy: results from 312 cases.Ann Thorac Surg2018;106:264-71

[24] Fuchs HF,Leers JM,Bruns CJ.Modular step-up approach to robot-assisted transthoracic esophagectomy-experience of a German high volume center.Transl Gastroenterol Hepatol2019;4:62 PMCID:PMC6737436

[25] Zhang H,Wang Z.The learning curve for robotic McKeown esophagectomy in patients with esophageal cancer.Ann Thorac Surg2018;105:1024-30

[26] Hernandez JM,Weber J.Defining the learning curve for robotic-assisted esophagogastrectomy.J Gastrointest Surg2013;17:1346-51

[27] Park S,Lee HJ,Kim YT.A study of the learning curve for robotic oesophagectomy for oesophageal cancer.Eur J Cardiothorac Surg2018;53:862-70

[28] Yang Y,Hua R.Assessment of quality outcomes and learning curve for robot-assisted minimally invasive McKeown esophagectomy.Ann Surg Oncol2021;28:676-84

[29] Rebecchi F,Salzano A,Morino M.Robot-assisted minimally invasive esophagectomy (RAMIE) with side-to-side semi-mechanical anastomosis: analysis of a learning curve.Updates Surg2022;74:907-16

[30] Grimminger PP,Hadzijusufovic E,Babic B.Change from hybrid to fully minimally invasive and robotic esophagectomy is possible without compromises.Thorac Cardiovasc Surg2019;67:589-96

[31] de Groot EM, Goense L, Kingma BF, van den Berg JW, Ruurda JP, van Hillegersberg R. Implementation of the robotic abdominal phase during robot-assisted minimally invasive esophagectomy (RAMIE): results from a high-volume center.Surg Endosc2023;37:1357-65 PMCID:PMC9945034

[32] Chao YK,Chuang WY.Transition from video-assisted thoracoscopic to robotic esophagectomy: a single surgeon's experience.Dis Esophagus2020;33:doz033

[33] Duan X,Chen C.Lymph node dissection around left recurrent laryngeal nerve: robot-assisted vs. video-assisted McKeown esophagectomy for esophageal squamous cell carcinoma.Surg Endosc2021;35:6108-16 PMCID:PMC7586865

[34] Zhang X,Yang Y.Robot assisted esophagectomy for esophageal squamous cell carcinoma.J Thorac Dis2018;10:3767-75 PMCID:PMC6051790

[35] Zhuo ZG,Song TN.From McKeown to Ivor Lewis, the learning curve for thoracic lymphadenectomy over the first 100 robotic esophagectomy cases: a retrospective study.J Thorac Dis2021;13:1543-52 PMCID:PMC8024862