Minimally invasive esophagectomy: Direction of the art

Central MessageThe direction of minimally invasive esophagectomy is supported by data, enabled surgical and technological innovation, controlled provider equipoise, positioned in our standard care.See Commentaries on pages 705, 707, 708. The care. See Thoracoscopic lobectomy an archetypal model how careful adoption surgery offers value health Thoracoscopy improves the quality compared with thoracotomy reducing pain, improving life (QOL), increasing probability completing adjuvant therapy, potentially even benefiting long-term survival.1Klapper J. D'Amico T.A. VATS versus open for lung cancer resection: moving toward a approach.J Natl Compr Canc Netw. 2015; 13: 162-164Crossref PubMed Scopus (53) Google Scholar consequently reduces care costs decreasing length stay, complications, facilitating speedier return to normal activities.2Geller A.D. Zheng H. Mathisen D.J. Wright C.D. Lanuti M. Relative incremental complications stage I non–small cell cancer.J Thorac Cardiovasc Surg. 2018; 155: 1804-1811Abstract Full Text PDF (18) Scholar,3Burt B.M. Kosinski A.S. Shrager J.B. Onaitis M.W. Weigel T. associated acceptable morbidity mortality patients predicted postoperative forced expiratory volume 1 second or diffusing capacity carbon monoxide less than 40% normal.J 2014; 148 (discussion 28-29.e11): 19-28Abstract (107) Available emerging evidence supports similar (MIE). Led largely Luketich colleagues, turn century established safety feasibility total laparoscopic/thoracoscopic MIE4Fernando H.C. Christie N.A. J.D. laparoscopic esophagectomy.Semin 2000; 12: 195-200Abstract (31) (referred hereafter as conventional MIE) its technical components including pyloroplasty,5Murphy T.J. Levy R.M. Crist L.R. Minimally pyloroplasty.Semin 2010; 22: 338-340Abstract (6) omental flap harvest anastomotic buttress,6Lu Awais O. Sarkaria I. Visintainer P. et al.Anastomotic after esophagectomy: influence omentoplasty propensity-weighted cohorts.J 2020; 159: 2096-2105Abstract (8) thoracoscopic intrathoracic anastomosis.7Levy esophagogastric anastomosis.Semin 256-258Abstract (7) Observational studies have since demonstrated no difference oncologic outcomes between MIE esophagectomy, these metrics include extent lymphadenectomy, margin status, survival.8Mitzman B. Lutfi W. Wang C.H. Krantz S. Howington J.A. Kim K.W. provides equivalent survival analysis National Cancer Database.Semin 2017; 29: 244-253Abstract (37) QOL essential outcome measure therapeutic intervention patients, has been shown improved relative esophagectomy.9Taioli E. Schwartz Lieberman-Cribbin Moskowitz G. van Gerwen Flores R. Quality esophageal cancer—a systematic review.Semin 377-390Abstract Corresponding emergence routine use increased globally over past decade. As example, among 6022 esophagectomies performed during period 2015 2018 39 centers around world, majority (53%) were using approaches.10Kuppusamy M.K. Low D.E. International Esodata Study Group (IESG) Evaluation international contemporary operative management trends 4-year study >6000 ECCG definitions online database.Ann October 14, ([Epub ahead print])Crossref (38) Two multicenter randomized trials comparing published last 8 years reviewed recently Journal.11Hofstetter W.L. Open hybrid join crowd, but do not throw away your abdominal retractors just yet.J 2019; 158: 1475-1478Abstract (5) TIME (Traditional Invasive vs Esophagectomy) trial was reported Lancet 2012 open, modified McKeown esophagectomy.12Biere S.S. Berge Henegouwen M.I. Maas Bonavina L. Rosman C. Garcia J.R. al.Minimally oesophagectomy oesophageal cancer: multicentre, open-label, randomised trial.Lancet. 2012; 379: 1887-1892Abstract (1227) MIRO (Oesphagectomie Pour par Voie Conventionnelle ou Coelio-Assisté) New England Journal Medicine 2019 Ivor Lewis laparoscopic/thoracotomy approach one fully laparotomy thoracotomy.13Mariette Markar S.R. Dabakuyo-Yonli T.S. Meunier Pezet D. Collet al.Hybrid cancer.N Engl J Med. 380: 152-162Crossref (397) There stay 30- 90-mortality either trial. Each significantly lower rates pneumonia following MIE, although this relatively high rate group (34%).12Biere Scholar,13Mariette differences R0 resection, disease-free at 3 years13Mariette Scholar,14Straatman der Wielen N. Cuesta M.A. Daams F. Roig three-year follow-up previously trial: trial.Ann 266: 232-236Crossref (358) (Table 1). Importantly, cohorts both trials, 2 surgery.15Maas al.Quality late results trial.World 39: 1986-1993Crossref (135) Scholar,16Mariette al.Health-related cancer, multicenter, phase III 271: 1023-1029Crossref (65) taught us that approaching abdomen laparoscopically major contributor short-term advantages MIE. Eliminating rationally expected further enhance benefits. Although yet level evidence, observational reduced decreased pneumonia, overall (totally invasive) approach.17Berlth Plum P.S. Chon S.H. Gutschow C.A. Bollschweiler Holscher A.H. Total adenocarcinoma pain esophagectomy.Surg Endosc. 32: 4957-4965Crossref (34) Scholar,18Burdall O.C. Boddy A.P. Fullick Blazeby Krysztopik Streets al.A comparative oesophagectomy.Surg 431-437Crossref (50) ScholarTable 1Comparison perioperative pathologic hybrid, MIEApproachTrialNPneumoniaLeak30-d mortalityR0 rateLN countOpenTIME5634%∗In-hospital rate.7%0%84%21 (4-47)Conventional MIETIME5912%∗In-hospital rate.12%2%92%20 (3-44)OpenMIRO10416.5%†30-day rate.7%1%98.1%22 (9-64)Hybrid MIEMIRO10312.8%†30-day rate.11%1%95.1%21 (7-76)LN, Lymph node; TIME, Traditional Versus Esophagectomy; MIRO, Oesphagectomie conventionnelle Coelio-Assistée; esophagectomy.∗ In-hospital rate.† 30-day rate. table new tab LN, esophagectomy. Advanced digital optics precision control robotic instrumentation rising popularity robot-assisted (RAMIE). A variety reports now RAMIE cancer,19Cerfolio R.J. Bryant Hawn M.T. Technical aspects early chest anastomosis.J 2013; 145: 90-96Abstract (89) Scholar,20Kim Hyung W.J. Lee C.Y. J.G. Haam S.J. Park I.K. al.Thoracoscopic assistance prone position.J 139: 53-59.e51Abstract (91) emerging. ROBOT (Robot-Assisted Thoraco-Laparoscopic Esophagectomy Transthoracic Resectable Esophageal Cancer) single-center, (n = 55) 54) via approach. In trial, 26% risk reduction groups outcomes, 90-day mortality. line data undergoing had functional recovery 14 days better 6 weeks.21van Sluis P.C. Horst May A.M. Schippers Brosens L.A.A. Joore H.C.A. al.Robot-assisted thoracolaparoscopic transthoracic resectable 269: 621-630Crossref (346) Similar seen greater (80%) which accentuated advantage (59%). Retrospective comparable across domains morbidity, survival.22Espinoza-Mercado Imai Borgella Sarkissian A. Serna-Gallegos Alban R.F. al.Does matter? Comparing robotic, invasive, esophagectomies.Ann 107: 378-385Abstract (60) Scholar,23Tagkalos Goense Hoppe-Lotichius Ruurda J.P. Babic Hadzijusufovic (RAMIE) (MIE) propensity-matched analysis.Dis Esophagus. 33: doz060Crossref (64) Level available; however, are being prospectively distal esophagus, ROBOT-2 (NCT04306458). It clear, capital maintenance system required platforms We aware rigorous comparison economic considerations RAMIE, anticipate publications relevant cost matrices next years. Given hospital complications,24Geller Gaissert Muniappan al.Relative 31: 290-299Abstract (13) it feasible hypothesize from could mitigate, some extent, relationship institutional remains controversial, standards recommended organizations vested (eg, minimum 20 year).25The Leapfrog GroupComplex Adult Surgery. Group, Washington, DC2019https://ratings.leapfroggroup.org/measure/hospital/complex-adult-surgeryGoogle Surprisingly, only 42% institutions participating Society Thoracic Surgeons (STS) General Database, least 5 year,26Society Surgery Database Task ForceThe composite score evaluating cancer.Ann 103: 1661-1667Abstract (56) analyses STS clear volume–outcome exception very low-volume (median 1.3 cases per year; [interquartile range, 0.7-1.7]) worse studies.26Society Scholar, 27Wright Kucharczuk J.C. O'Brien S.M. Grab Allen M.S. database. Predictors database adjustment model.J 2009; 137 596): 587-595Abstract (292) 28Jacobs R.C. Groth Farjah Wilson Petersen L.A. Massarweh N.N. Potential impact “Take Volume Pledge” access gastrointestinal surgery.Ann 270: 1079-1089Crossref (24) Whereas alone should limit transition thoracic surgeons, highly complex, nuanced operations be approached responsibly. learning curve studied such time, intraoperative blood loss, number resected lymph nodes, balance literature would suggest proficiency occurs 35-40 cases.29Tapias L.F. Morse C.R. description curve.J Am Coll 218: 1130-1140Abstract (115) Scholar,30White Kucukak D.N. Mazzola Zhang Y. Swanson excellent operation experience.J 157: 783-789Abstract (20) retrospective 646 investigated effect primary leak. This average 119 achieve plateau leak about 8%, starting 18.8%.31van Workum Stenstra Berkelmans G.H.K. Slaman A.E. Gisbertz al.Learning study.Ann 88-94Crossref (172) Learning suggested achieved 40-70 cases.32Sarkaria I.S. Rizk N.P. Grosser Goldman Finley Ghanie al.Attaining robotic-assisted while maximizing procedure development.Innovations (Phila). 2016; 11: 268-273Crossref (54) Scholar,33van Hillegersberg 312 cases.Ann 106: 264-271Abstract (86) Supported proven benefit surgeons reasonably their stepwise fashion intermediate laparoscopy/thoracotomy laparotomy/thoracoscopy. Universal discussion section all manuscripts highlighted frequently leaders field importance structured training proctorship those operations. One most technically challenging construction anastomosis greatest sources Among within database, frequency statistically different overall. However, leaks managed nonoperatively (8.3%) (4.3%).34Sihag H.A. Schipper P.H. Database.Ann 101 1288-9): 1281-1288Abstract (169) techniques fashioning used practice stapled EEA thoracoscopic35Okusanya O.T. Hess N.R. Nason K.S. Sanchez M.V. al.Robotic assisted (RAMIE): University Pittsburgh Medical Center initial experience.Ann Cardiothorac 6: 179-185Crossref (48) transoral anvil placement,36Meredith K. Huston Andacoglu Shridhar Safety Ivor-Lewis esophagectomy.Dis 31https://doi.org/10.1093/dote/doy005Crossref (16) Collard technique,37Kesler K.A. Ramchandani N.K. Jalal S.I. Stokes Mankins M.R. Ceppa al.Outcomes novel technique.J 156: 1739-1745.e1731Abstract (15) Scholar,38Hagen technique: potential esophagectomy.J 1746-1747Abstract (1) “handsewn” technique.39Cerfolio Wei Minnich Robotic lessons learned.Semin 28: 160-169Abstract any rigorously submit robotics renew opportunity compare benefits limitations sewn techniques. can considered cancer. driven innovation responsibly regulated surgeons. Robotics firmly integrated natural progression Evidence efficacy accruing nodal dissection, efficacy, QOL, cost-effectiveness evaluated steady forward advancement art science will likely bring increase approaches development clinically applications fluorescence imaging conduit perfusion40Okusanya Lu Intraoperative near infrared assessment gastric conduit.J Dis. S750-S754Crossref Scholar,41Van Daele Van Nieuwenhove Ceelen Vanhove Braeckman B.P. Hoorens al.Near-infrared guided reconstructive surgery: review.World Gastrointest Oncol. 250-263Crossref mapping regional sentinel nodes.42Hachey K.J. Gilmore D.M. Armstrong Harris S.E. Hornick J.L. Colson Y.L. al.Safety near-infrared image-guided lymphatic nodes 152: 546-554Abstract (49) forward, stimulating, brisk.