Robot-Assisted Minimally Invasive Esophagectomy with Intrathoracic Anastomosis (Ivor Lewis): Promising Results in 100 Consecutive Patients (the European Experience)

Abstract Robotic-assisted minimally invasive esophagectomy (RAMIE) represents an established approach for the treatment of esophageal cancer. Aim of this study is to evaluate the feasibility and safety of our technique for performing the intrathoracic anastomosis during RAMIE.All the procedures were performed by the same surgeon using the same technique for performing the intrathoracic anastomosis. Intraoperative and postoperative outcomes were recorded. Postoperative complications were classified according to the Esophagectomy Complications Consensus Group (ECCG); the primary outcome was the evaluation of the feasibility and safety of our technique. From 2016 to 2021, 204 patients underwent Ivor Lewis RAMIE at our Center. Two patients (0.9%) were converted during the thoracic phase. The anastomosis was completed in all the other patients forming complete anastomotic rings. The median duration for the robotic-assisted thoracoscopic phase was 224 minutes. Twenty-two of the RAMIE-Ivor Lewis patients had an anastomotic leakage (10.3%). The overall 90-day postoperative mortality was 1.9%. The procedure resulted to be feasible and safe in our cohort of patients.

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P123 ROBOT ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY (RAMIE4) WITH INTRATHORACIC ANASTOMOSIS: PROMISING RESULTS AND LESSONS LEARNED IN 100 PATIENTS

Diseases of the Esophagus ◽

10.1093/dote/doz092.123 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

E Tagkalos ◽

der Sluis P C van ◽

E Hadzijusufovic ◽

B Babic ◽

E Uzun ◽

...

Keyword(s):

Esophageal Cancer ◽

Postoperative Complications ◽

Minimally Invasive ◽

Minimally Invasive Esophagectomy ◽

Case Series ◽

Oncologic Outcomes ◽

Robot Assisted ◽

Short Term ◽

Intrathoracic Anastomosis ◽

Invasive Esophagectomy

Abstract Aim The aim of this study was to describe postoperative complications and short-term oncologic outcomes for RAMIE4 with intrathoracic anastomosis for esophageal cancer within our case series of 100 consecutive patients. Background & Methods Robot assisted minimally-invasive esophagectomy (RAMIE) with intrathoracic anastomosis is gaining popularity as a treatment for esophageal cancer. In this study, we present the results of 100 RAMIE procedures using the da Vinci Xi robotic system (RAMIE4). The aim of this study was to describe postoperative complications and short-term oncologic outcomes for RAMIE4 within our case series of 100 consecutive patients. Between January 2017 and February 2019, data of 100 consecutive patients with esophageal carcinoma undergoing modified Ivor-Lewis esophagectomy were prospectively collected. All operations were performed by the same surgeon using an identical intrathoracic anastomotic reconstruction technique with the same perioperative management and pain control regimen. Intra-operatively and post operatively complications were graded according to definitions stated by the Esophagectomy Complications Consensus Group (ECCG). Results Mean duration of the surgical procedure was 416 min (± 80). In total, 70 patients (70%) had an uncomplicated operative procedure and postoperative recovery. Pulmonary complications were most common and were observed in 17 patients (17 %). Anastomotic leakage was observed in 8 patients (8%). Median ICU stay was 1 day and median overall postoperative hospital stay was 11 days. 30 day mortality was 1%. A R0 resection was reached in 92% of patients with a median number of 29 dissected lymph nodes. Conclusion RAMIE4 with intrathoracic anastomosis for esophageal cancer or cancer located in the esophagus was technically feasible and safe. Postoperative complications and short term oncologic results were comparable to the highest international standards nowadays. These results could only be obtained due to a structured RAMIE training pathway. The superiority of RAMIE compared to conventional minimally invasive esophagus is currently investigated in multiple randomized controlled trials. Results of these trials will define the role for RAMIE for patients with esophageal cancer in the future.

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Multicenter Experience in Robot-Assisted Minimally Invasive Esophagectomy — a Comparison of Hybrid and Totally Robot-Assisted Techniques

Journal of Gastrointestinal Surgery ◽

10.1007/s11605-021-05044-8 ◽

2021 ◽

Author(s):

Peter P. Grimminger ◽

Julia I. Staubitz ◽

Daniel Perez ◽

Tarik Ghadban ◽

Matthias Reeh ◽

...

Keyword(s):

Respiratory Failure ◽

Minimally Invasive ◽

Anastomotic Leak ◽

Minimally Invasive Esophagectomy ◽

Robot Assisted ◽

Ivor Lewis ◽

Invasive Esophagectomy ◽

Open Esophagectomy ◽

Advantages And Disadvantages ◽

Risk Ratios

Abstract Background Oncological esophageal surgery has evolved significantly in the last decades. From open esophagectomy over (hybrid) minimally invasive surgery, nowadays, robot-assisted minimally invasive esophagectomy (RAMIE) approaches are applied. Current techniques require an analysis of possible advantages and disadvantages indicating the direction towards a novel gold standard. Methods Robot-assisted Ivor Lewis esophagectomies, performed in the period from April 2017 to June 2019 in five German centers (Berlin, Cologne, Hamburg, Kiel, Mainz), were included in this study. Pre-, intra-, and postoperative parameters were assessed. Cases were grouped for hybrid (H-RAMIE) versus totally robot-assisted (T-RAMIE) approaches. Postoperative parameters and complications were compared using risk ratios. Results A total of 175 operations were performed as T-RAMIE and 67 as H-RAMIE. Patient age (median age 62 years) and sex (83.1% male) were similarly distributed in both groups. Median duration of esophagectomy was significantly lower in the T-RAMIE group (385 versus 427 min, p < 0.001). The risks of “overall morbidity” (32.0 versus 47.8%; risk ratio [RR], 95% confidence interval (CI): 1.5, 1.1–2.1; p = 0.026), “anastomotic leak” (10.3 versus 22.4%; RR, CI: 2.2, 1.2–4.1; p = 0.020), and “respiratory failure” (1.1 versus 7.5%; RR, CI: 6.5, 1.3–32.9; p = 0.019) were significantly higher in case of H-RAMIE. Conclusions In the five participating German centers, T-RAMIE was the preferred procedure (72.3% of operations). In comparison to H-RAMIE, T-RAMIE was associated with a significantly reduced risk of postoperative morbidity, anastomotic leak, and respiratory failure as well as a significantly reduced time necessary for esophagectomy.

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Technical details of the hand-sewn and circular-stapled anastomosis in robot-assisted minimally invasive esophagectomy

Diseases of the Esophagus ◽

10.1093/dote/doaa055 ◽

2020 ◽

Vol 33 (Supplement_2) ◽

Author(s):

Eline M de Groot ◽

Thorben Möller ◽

B Feike Kingma ◽

Peter P Grimminger ◽

Thomas Becker ◽

...

Keyword(s):

Minimally Invasive ◽

Anastomotic Leakage ◽

Moving Average ◽

Minimally Invasive Esophagectomy ◽

High Volume ◽

Stapled Anastomosis ◽

Robot Assisted ◽

Intrathoracic Anastomosis ◽

Invasive Esophagectomy ◽

Technical Details

SUMMARY The circular mechanical and hand-sewn intrathoracic anastomosis are most often used in robot-assisted minimally invasive esophagectomy (RAMIE). The aim of this study was to describe the technical details of both techniques that were pioneered in two high volume centers for RAMIE. A prospectively maintained database was used to identify patients with esophageal cancer who underwent RAMIE with intrathoracic anastomosis. The primary outcome was anastomotic leakage, which was analyzed using a moving average curve. For the hand-sewn anastomosis, video recordings were reviewed to evaluate number of sutures and distances between the anastomosis and the longitudinal staple line or gastric conduit tip. Between 2016 and 2019, a total of 68 patients with a hand-sewn anastomosis and 60 patients with a circular-stapled anastomosis were included in the study. For the hand-sewn anastomosis, the moving average curve for anastomotic leakage (including grade 1–3) started at a rate of 40% (cases 1–10) and ended at 10% (cases 59–68). For the circular-stapled anastomosis, the moving average started at 10% (cases 1–10) and ended at 20% (cases 51–60). This study showed the technical details and refinements that were applied in developing two different anastomotic techniques for RAMIE. Results markedly improved during the period of development with specific changes in technique for the hand-sewn anastomosis. The circular-stapled anastomosis showed a more stable rate of performance.

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European consensus on essential steps of Minimally Invasive Ivor Lewis and McKeown Esophagectomy through Delphi methodology

Surgical Endoscopy ◽

10.1007/s00464-021-08304-5 ◽

2021 ◽

Author(s):

Yassin Eddahchouri ◽

◽

Frans van Workum ◽

Frits J. H. van den Wildenberg ◽

Mark I. van Berge Henegouwen ◽

...

Keyword(s):

Minimally Invasive ◽

Expert Panel ◽

Minimally Invasive Esophagectomy ◽

Round Table ◽

Round Table Discussion ◽

Ivor Lewis ◽

Delphi Methodology ◽

Invasive Esophagectomy ◽

European Consensus ◽

Mckeown Esophagectomy

Abstract Background Minimally invasive esophagectomy (MIE) is a complex and technically demanding procedure with a long learning curve, which is associated with increased morbidity and mortality. To master MIE, training in essential steps is crucial. Yet, no consensus on essential steps of MIE is available. The aim of this study was to achieve expert consensus on essential steps in Ivor Lewis and McKeown MIE through Delphi methodology. Methods Based on expert opinion and peer-reviewed literature, essential steps were defined for Ivor Lewis (IL) and McKeown (McK) MIE. In a round table discussion, experts finalized the lists of steps and an online Delphi questionnaire was sent to an international expert panel (7 European countries) of minimally invasive upper GI surgeons. Based on replies and comments, steps were adjusted and rephrased and sent in iterative fashion until consensus was achieved. Results Two Delphi rounds were conducted and response rates were 74% (23 out of 31 experts) for the first and 81% (27 out of 33 experts) for the second round. Consensus was achieved on 106 essential steps for both the IL and McK approach. Cronbach’s alpha in the first round was 0.78 (IL) and 0.78 (McK) and in the second round 0.92 (IL) and 0.88 (McK). Conclusions Consensus among European experts was achieved on essential surgical steps for both Ivor Lewis and McKeown minimally invasive esophagectomy.

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Robot assisted minimally invasive esophagectomy: safety, perioperative morbidity and short-term oncological outcome—a single institution experience

Journal of Robotic Surgery ◽

10.1007/s11701-021-01274-9 ◽

2021 ◽

Author(s):

Assif Iqbal Sayed ◽

Shaifali Goel ◽

Abhishek Aggarwal ◽

Shivendra Singh

Keyword(s):

Minimally Invasive ◽

Minimally Invasive Esophagectomy ◽

Oncological Outcome ◽

Single Institution ◽

Robot Assisted ◽

Short Term ◽

Perioperative Morbidity ◽

Invasive Esophagectomy

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Modified Intrathoracic Esophagogastrostomy with Minimally Invasive Robot-Assisted Ivor-Lewis Esophagectomy for Cancer

Digestive Surgery ◽

10.1159/000495361 ◽

2018 ◽

Vol 36 (3) ◽

pp. 218-225 ◽

Cited By ~ 2

Author(s):

Wen-Ping Wang ◽

Long-Qi Chen ◽

Han-Lu Zhang ◽

Yu-Shang Yang ◽

Song-Lin He ◽

...

Keyword(s):

Minimally Invasive ◽

Circular Stapler ◽

Purse String Suture ◽

Robot Assisted ◽

Purse String ◽

Ivor Lewis ◽

Intrathoracic Anastomosis ◽

Ivor Lewis Esophagectomy ◽

Estimated Blood Loss ◽

Esophagectomy For Cancer

Background: Intrathoracic esophagogastrostomy plays an important role in minimally invasive Ivor-Lewis esophagectomy for cancer. Intrathoracic anastomosis with robot-assisted Ivor-Lewis esophagectomy (RAILE) includes hand-sewn and circular stapler methods, which remain technically challenging. In this study, we modified the techniques for intrathoracic anastomosis at RAILE, in order to simplify the complex procedures. Methods: “Side-insertion” technique was used for anvil placement and purse string suture for intrathoracic anastomosis at RAILE. Medical records for consecutive patients who had undergone robot-assisted minimally invasive Ivor-Lewis esophagectomy for cancer between January 2015 and June 2018 were analyzed. Results: A total of consecutive 31 patients were enrolled. There was no conversion to open thoracotomy in this cohort. Mean operation duration in the robotic group was 387.4 ± 68.2 min. Median estimated blood loss was 110 mL (range 50–400 mL). Two patients (6.5%) had postoperative anastomotic leak. No postoperative reoperation was needed and there were no mortality. Six patients (19.4%) had anastomotic stricture and 2 patients of them needed endoscopic dilation. Conclusion: RAILE is safe and feasible. Our modified procedure highlighting the “side-insertion” method may simplify the process of intrathoracic anvil placement and purse string suture for anastomosis at RAILE.

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