Comparison of conventional and robotic-assisted minimally invasive esophagectomy for esophageal cancer

Abstract

Conventional minimally invasive esophagectomy (MIE) and robotic-assisted MIE (RAMIE) have increased in prevalence across the world for the management of esophageal cancer. Both minimally invasive modalities have demonstrated decreased morbidity, with preservation of oncologic outcomes, when compared to open esophagectomy. A limitation of conventional MIE is the use of rigid instruments with 2D visualization leading to a prolonged learning curve and extended operative times. RAMIE offers both improved visualization with 3D video capable of magnification and full dexterity with wristed instruments. To date, retrospective and randomized controlled trials demonstrate overall higher harvest during lymphadenectomy by RAMIE compared to MIE, though more studies are needed to determine definitive impact on oncologic outcomes and long-term survival. RAMIE showed superiority for lymphadenectomy after neoadjuvant therapy and for bilateral recurrent laryngeal nerve (RLN) lymphadenectomy with decreased rates of RLN paralysis. Current data suggests no overall cost difference between the two modalities. Ongoing studies will further clarify the role for RAMIE in esophageal adenocarcinoma (EA) and the outcomes of robotic/MIE hybrid techniques.

Keywords

Esophageal cancer / robotic-assisted minimally invasive esophagectomy / minimally invasive esophagectomy / esophageal cancer surgery

References

[1] Sung H,Siegel RL.Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.CA Cancer J Clin2021;71:209-49

[2] Surveillance, Epidemiology, and End Results Program. Cancer stat facts: esophageal cancer. https://seer.cancer.gov/statfacts/html/esoph.html. (accessed 2025-02-14)

[3] van Hagen P, Hulshof MC, van Lanschot JJ, et al; CROSS Group. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med. 2012;366:2074-84.

[4] Shapiro J, van Lanschot JJB, Hulshof MCCM, et al; CROSS study group. Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer (CROSS): long-term results of a randomised controlled trial. Lancet Oncol. 2015;16:1090-8.

[5] Mertens AC, Kalff MC, Eshuis WJ, Van Gulik TM, Van Berge Henegouwen MI, Gisbertz SS; Dutch Upper GI Cancer Audit group. Transthoracic versus transhiatal esophagectomy for esophageal cancer: a nationwide propensity score-matched cohort analysis. Ann Surg Oncol. 2021;28:175-83. PMCID:PMC7752871

[6] Khaitan PG,Thibault D.Robotic esophagectomy trends and early surgical outcomes: the US experience.Ann Thorac Surg2023;115:710-7

[7] 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

[8] Straatman J,Cuesta MA.Minimally invasive versus open esophageal resection: three-year follow-up of the previously reported randomized controlled trial: the TIME trial.Ann Surg2017;266:232-6

[9] van Workum F,Berkelmans GHK.Learning curve and associated morbidity of minimally invasive esophagectomy: a retrospective multicenter study.Ann Surg2019;269:88-94

[10] van der Sluis PC,May AM.Robot-assisted minimally invasive thoracolaparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer: a randomized controlled trial.Ann Surg2019;269:621-30

[11] Babic B,Jung JO.Robot-assisted minimally invasive esophagectomy (RAMIE) vs. hybrid minimally invasive esophagectomy: propensity score matched short-term outcome analysis of a European high-volume center.Surg Endosc2022;36:7747-55 PMCID:PMC9485091

[12] Fujita T,Ozaki A.Propensity-matched analysis of the short-term outcome of robot-assisted minimally invasive esophagectomy versus conventional thoracoscopic esophagectomy in thoracic esophageal cancer.World J Surg2022;46:1926-33

[13] Morimoto Y,Ishikawa A.Short-term outcomes of robot-assisted minimally invasive esophagectomy with extended lymphadenectomy for esophageal cancer compared with video-assisted minimally invasive esophagectomy: a single-center retrospective study.Asian J Endosc Surg2022;15:270-8

[14] Tsunoda S,Hisamori S.Lower incidence of postoperative pulmonary complications following robot-assisted minimally invasive esophagectomy for esophageal cancer: propensity score-matched comparison to conventional minimally invasive esophagectomy.Ann Surg Oncol2021;28:639-47

[15] Ekeke CN,Luketich JD.Comparison of robotic-assisted minimally invasive esophagectomy versus minimally invasive esophagectomy: a propensity-matched study from a single high-volume institution.J Thorac Cardiovasc Surg2023;166:374-82.e1 PMCID:PMC11232031

[16] Zhang Y,Cao Y.Robotic versus conventional minimally invasive esophagectomy for esophageal cancer: a meta-analysis.Ann Surg2023;278:39-50

[17] Angeramo CA,Casas MA.Minimally invasive Ivor Lewis esophagectomy: robot-assisted versus laparoscopic-thoracoscopic technique. Systematic review and meta-analysis.Surgery2021;170:1692-701

[18] Huang Y,Song JD.Early outcomes with robot-assisted vs. minimally invasive esophagectomy for esophageal cancer: a systematic review and meta-analysis of matched studies.Eur Rev Med Pharmacol Sci2021;25:7887-97

[19] Zhou J,Chen L.McKeown esophagectomy: robot-assisted versus conventional minimally invasive technique-systematic review and meta-analysis.Dis Esophagus2022;35:doac011

[20] Weijs TJ,Luyer MDP.New insights into the surgical anatomy of the esophagus.J Thorac Dis2017;9:S675-80 PMCID:PMC5538986

[21] Hoelzen JP,Roy D.Robotic-assisted esophagectomy with total mesoesophageal excision enhances R0-resection in patients with esophageal cancer: a single-center experience.Surgery2024;176:721-9

[22] Kang CH,Park JH.Long-term survival analysis of robotic esophagectomy for esophageal cancer.Dis Esophagus2024;37:doae054

[23] Byiringiro I,Nandipati KC.Long-term survival outcomes associated with robotic-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer.Surg Endosc2023;37:4018-27

[24] Kingma BF, Grimminger PP, van der Sluis PC, et al; UGIRA Study Group. Worldwide techniques and outcomes in robot-assisted minimally invasive esophagectomy (RAMIE): results from the multicenter international registry. Ann Surg. 2022;276:e386-92.

[25] 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

[26] Chao YK,Wen YW.Robotic-assisted esophagectomy vs video-assisted thoracoscopic esophagectomy (REVATE): study protocol for a randomized controlled trial.Trials2019;20:346 PMCID:PMC6558787

[27] Chao YK,Wen YW.552. Comparing robotic esophagectomy to video-assisted thoracoscopic esophagectomy for esophageal squamous cell carcinoma: results from the REVATE randomized clinical trial.Dis Esophagus2024;37:doae057.278

[28] 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

[29] Klotz R,Schmidt T.Overall morbidity after total minimally invasive keyhole oesophagectomy versus hybrid oesophagectomy (the MICkey trial): study protocol for a multicentre randomized controlled trial.Trials2023;24:175 PMCID:PMC9999550

[30] National Library of Medicine. RAE versus MIE in patients with esophageal cancer after neoadjuvant therapy. https://clinicaltrials.gov/study/NCT06012214?term=esophagectomy&limit=100&intr=Robotic&rank=3#publications. (accessed 2025-02-14)

[31] National Library of Medicine. ClinicalTrials.Gov. https://clinicaltrials.gov/. (accessed 2025-02-14)

[32] Knitter S,Winter A.Robotic-assisted Ivor Lewis esophagectomy is safe and cost equivalent compared to minimally invasive esophagectomy in a tertiary referral center.Cancers2023;16:112 PMCID:PMC10778089

[33] Goense L,van der Horst S.Cost analysis of robot-assisted versus open transthoracic esophagectomy for resectable esophageal cancer. Results of the ROBOT randomized clinical trial.Eur J Surg Oncol2023;49:106968

[34] Liu F,Yang W.Minimally invasive or open esophagectomy for treatment of resectable esophageal squamous cell carcinoma? Answer from a real-world multicenter study.Ann Surg2023;277:e777-84

[35] Tagkalos E,Hoppe-Lotichius M.Robot-assisted minimally invasive esophagectomy (RAMIE) compared to conventional minimally invasive esophagectomy (MIE) for esophageal cancer: a propensity-matched analysis.Dis Esophagus2020;33:doz060