Robot-assisted hand-sewn intrathoracic anastomosis after esophagectomy

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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P103 A HAND-SEWN INTRATHORACIC ANASTOMOSIS IN ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY (RAMIE): A DETAILED DESCRIPTION OF TECHNIQUE AND OUTCOMES

Diseases of the Esophagus ◽

10.1093/dote/doz092.103 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

E M de Groot ◽

B F Kingma ◽

R van Hillegersberg ◽

J P Ruurda

Keyword(s):

Anastomotic Leakage ◽

Moving Average ◽

Minimally Invasive Esophagectomy ◽

Leakage Rate ◽

Gastric Conduit ◽

Robot Assisted ◽

Intrathoracic Anastomosis ◽

Invasive Esophagectomy ◽

Anastomotic Leakage Rate ◽

Technical Details

Abstract Aim The aim of this study was to describe a technique that was developed and refined to construct a hand-sewn intrathoracic anastomosis during robot-assisted minimally invasive esophagectomy (RAMIE). Background & Methods Whilst some case series have reported promising results of a hand-sewn intrathoracic anastomosis during RAMIE, the exact techniques were often not described in detail. Therefore, the current single-center retrospective study was designed to provide a detailed and reproducible technical description of a hand-sewn, intrathoracic anastomosis that was developed and refined for patients who underwent RAMIE in a high volume center for esophageal cancer surgery (2016-2018). Video recordings were reviewed to evaluate technical details regarding the anastomosis, including number of sutures and distances between the anastomosis and the longitudinal staple line or gastric conduit tip. Technical details and distances were extracted and measured by using video analysis software. Moving average analyses were performed to evaluate whether the anastomotic leakage rate changed over the consecutive cases. Results A total of 68 patients were included in the study. For creation of the anastomosis, the gastric conduit was opened on a median distance of 19 millimeters (range 0-66) from the gastric conduit tip. After initially performing end-to-end anastomoses, a switch was made to an end-to-side anastomosis for the majority of 55 patients (81%). A median total of 27 sews (range 20-38) were required to close the anastomosis. In the last 22 patients of the cohort (32%), 4 tension release stitches were placed after circular suturing of the anastomosis. A re-inforcing omental wrap was positioned around the anastomosis in 64 patients (94%). The moving average curve for anastomotic leakage started at a rate of 40% (cases 1-10) and ended at 10% (cases 59-68). Conclusion This is the first study to report technical features and outcomes of a hand-sewn intrathoracic anastomosis during RAMIE in detail. Although an acceptable anastomotic leakage rate was observed in the final inclusion phase, a hand-sewn intrathoracic anastomosis during RAMIE may carry a substantial learning curve.

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

Journal of Gastrointestinal Surgery ◽

10.1007/s11605-019-04510-8 ◽

2020 ◽

Cited By ~ 8

Author(s):

Pieter Christiaan van der Sluis ◽

Evangelos Tagkalos ◽

Edin Hadzijusufovic ◽

Benjamin Babic ◽

Eren Uzun ◽

...

Keyword(s):

Minimally Invasive ◽

Minimally Invasive Esophagectomy ◽

Robot Assisted ◽

Ivor Lewis ◽

Intrathoracic Anastomosis ◽

Invasive Esophagectomy ◽

European Experience

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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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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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