State of the art in esophagectomy: robotic assistance in the abdominal phase

Over the years, robot-assisted esophagectomy gained popularity. The current literature focused mainly on robotic assistance in the thoracic phase, whereas the implementation of robotic assistance in the abdominal phase is lagging behind. Advantages of adding a robotic system to the abdominal phase include robotic stapling and the increased surgeon's independency. In terms of short-term outcomes and lymphadenectomy, robotic assistance is at least equal to laparoscopy. Yet high quality evidence to conclude on this topic remains scarce. This review focuses on the evidence of robotic assistance in the abdominal phase of esophagectomy

Association Between Physical Activity and Pancreatic Cancer Risk and Mortality:A Systematic Review and Meta-Analysis

Background: Physical activity has been associated with a lower risk of various types of cancer and reduced cancer-specific mortality. Less is known about its impact on pancreatic cancer. The aim of this systematic review and meta-analysis was to summarize evidence on the association between physical activity and pancreatic cancer risk and mortality. Methods: PubMed and Embase were searched until May 2024 for studies examining physical activity in relation to pancreatic cancer incidence and mortality. Summary risk estimates for highest vs. lowest physical activity levels were calculated using a random-effects model. The risk of publication bias was assessed with a funnel plot and Egger’s regression test. Results: A total of seven case–control and eighteen prospective cohort studies were included that investigated the association between physical activity and pancreatic cancer incidence. Our meta-analysis showed a summary estimate of 0.75 (95% CI 0.64–0.88) for case–control studies (I2 = 23%, n = 7) and a summary estimate of 0.91 (95% CI 0.86–0.97) for prospective cohort studies (I2 = 5%, n = 18). Among the six prospective cohort studies that assessed pancreatic cancer mortality, the summary estimate was 1.03 (95% CI 0.83–1.27), I2 = 50%. Conclusions: Higher levels of physical activity were associated with reduced pancreatic cancer risk. Evidence from a limited number of studies suggests that pre-diagnosis physical activity does not affect pancreatic cancer mortality.</p

Cost analysis of robot-assisted versus open transthoracic esophagectomy for resectable esophageal cancer. Results of the ROBOT randomized clinical trial

Background: The previously published ROBOT trial demonstrated that robot assisted minimally invasive esophagectomy (RAMIE) is associated with a lower percentage of postoperative complications compared to open esophagectomy (OTE) for patients with esophageal cancer. The implications of these results on healthcare costs are important given the increased attention for cost-reduction in healthcare. Therefore the aim of this study was to report the hospital costs of RAMIE compared to OTE as treatment for esophageal cancer. Methods: The ROBOT trial randomized 112 patients with esophageal cancer between RAMIE and OTE through January 2012 and August 2016 in a single tertiary care academic centre in the Netherlands. The primary outcome of the current study was hospital costs from the day of esophagectomy until 90 days after discharge based on Time-Driven Activity-Based Costing methodology. Secondary outcomes included the incremental cost-effectiveness ratio per complication prevented and risk factors for increased hospital costs. Results: Of the 112 included patients, 109 patients underwent an esophagectomy, of whom 54 RAMIE and 55 OTE. The mean total hospital costs were comparable between RAMIE €40211 and OTE €39495 (mean difference €-715; bias-corrected and accelerated confidence interval € −14831 to 14783, p = 0.932). At a willingness-to-pay threshold of €20.000 to €25.000 (i.e. estimated additional costs to the hospital to treat patients with a complication) RAMIE had a probability 62%–70% of being cost effective to prevent postoperative complications. In multivariable regression analysis, major postoperative complications were the main driver of hospital costs after esophagectomy (€31839, p = 0.009). Conclusion: In this randomized trial RAMIE resulted in fewer postoperative complications compared to OTE without increasing total hospital costs.</p

Use of ileostomy versus colostomy as a bridge to surgery in left-sided obstructive colon cancer:retrospective cohort study

BACKGROUND: Colorectal cancer causes the majority of large bowel obstructions and surgical resection remains the gold standard for curative treatment. There is evidence that a deviating stoma as a bridge to surgery can reduce postoperative mortality rate; however, the optimal stoma type is unclear. The aim of this study was to compare outcomes between ileostomy and colostomy as a bridge to surgery in left-sided obstructive colon cancer.METHODS: This was a national, retrospective population-based cohort study with 75 contributing hospitals. Patients with radiological left-sided obstructive colon cancer between 2009 and 2016, where a deviating stoma was used as a bridge to surgery, were included. Exclusion criteria were palliative treatment intent, perforation at presentation, emergency resection, and multivisceral resection.RESULTS: A total of 321 patients underwent a deviating stoma; 41 (12.7 per cent) ileostomies and 280 (87.2 per cent) colostomies. The ileostomy group had longer length of stay (median 13 (interquartile range (i.q.r.) 10-16) versus 9 (i.q.r. 6-14) days, P = 0.003) and more nutritional support during the bridging interval. Both groups showed similar complication rates in the bridging interval and after primary resection, including anastomotic leakage. Stoma reversal during resection was more common in the colostomy group (9 (22.0 per cent) versus 129 (46.1 per cent) for ileostomy and colostomy respectively, P = 0.006).CONCLUSION: This study demonstrated that patients having a colostomy as a bridge to surgery in left-sided obstructive colon cancer had a shorter length of stay and lower need for nutritional support. No difference in postoperative complications were found.</p

Use of ileostomy versus colostomy as a bridge to surgery in left-sided obstructive colon cancer:retrospective cohort study

BACKGROUND: Colorectal cancer causes the majority of large bowel obstructions and surgical resection remains the gold standard for curative treatment. There is evidence that a deviating stoma as a bridge to surgery can reduce postoperative mortality rate; however, the optimal stoma type is unclear. The aim of this study was to compare outcomes between ileostomy and colostomy as a bridge to surgery in left-sided obstructive colon cancer.METHODS: This was a national, retrospective population-based cohort study with 75 contributing hospitals. Patients with radiological left-sided obstructive colon cancer between 2009 and 2016, where a deviating stoma was used as a bridge to surgery, were included. Exclusion criteria were palliative treatment intent, perforation at presentation, emergency resection, and multivisceral resection.RESULTS: A total of 321 patients underwent a deviating stoma; 41 (12.7 per cent) ileostomies and 280 (87.2 per cent) colostomies. The ileostomy group had longer length of stay (median 13 (interquartile range (i.q.r.) 10-16) versus 9 (i.q.r. 6-14) days, P = 0.003) and more nutritional support during the bridging interval. Both groups showed similar complication rates in the bridging interval and after primary resection, including anastomotic leakage. Stoma reversal during resection was more common in the colostomy group (9 (22.0 per cent) versus 129 (46.1 per cent) for ileostomy and colostomy respectively, P = 0.006).CONCLUSION: This study demonstrated that patients having a colostomy as a bridge to surgery in left-sided obstructive colon cancer had a shorter length of stay and lower need for nutritional support. No difference in postoperative complications were found.</p

Robotic- assisted minimally invasive Ivor-Lewis handsewn anastomosis technique and outcomes from a large-volume European centre

In minimally invasive transthoracic esophagectomy, intrathoracic anastomoses are usually performed with stapling devices to avoid a technically challenging handsewn technique in the upper mediastinum. Few have published about handsewn anastomotic techniques due to the technically demanding requirements for suturing with rigid instruments in the thoracic cavity. With robot-assisted minimally invasive esophagectomy (RAMIE), the robot provides increased dexterity, enabling construction of a hand-sewn intrathoracic anastomosis. This study aimed to evaluate the outcomes of our technique for hand-sewn intrathoracic anastomosis in RAMIE, following the initial learning phase between 2016 and 2018 in UMC Utrecht. Patients who underwent RAMIE with a robot-assisted hand-sewn intrathoracic anastomosis were included in this retrospective study. Data were extracted from a prospectively maintained institutional database. Key technique steps included esophageal stay-sutures, use of barbed sutures for the anastomosis, placement of tension-releasing stitches, and covering of the anastomosis with omentum. The primary outcome was anastomotic leakage; secondary outcomes included anastomotic stricture rate and duration of anastomosis construction. Between 1 November 2019 and 30 May 2023, 89 consecutive patients were included. Anastomotic leakage (defined by the Esophageal Complications Consensus Group) occurred in 11 patients (12.4%), which involved a grade I leak in four patients (4.5%), grade II leak in one patient (1.1%), and grade III leakage in six patients (6.7%). The median duration of anastomosis creation was 33 minutes (range, 23-55 minutes). Stricture rate was 32.6% (29 patients) at 1 year post-operatively for which dilation was needed for all patients. This study shows that a robot-assisted hand-sewn intrathoracic anastomosis in RAMIE is feasible, safe, and reliable

Sex-related differences in oncologic outcomes, operative complications and health-related quality of life after curative-intent oesophageal cancer treatment: multicentre retrospective analysis

Background: Oesophageal cancer, in particular adenocarcinoma, has a strong male predominance. However, the impact of patient sex on operative and oncologic outcomes and recovery of health-related quality of life is poorly documented, and was the focus of this large multicentre cohort study. Methods: All consecutive patients who underwent oncological oesophagectomy from 2009 to 2015 in the 20 European iNvestigation of SUrveillance after Resection for Esophageal cancer study group centres were assessed. Clinicopathologic variables, therapeutic approach, postoperative complications, survival and health-related quality of life data were compared between male and female patients. Multivariable analyses adjusted for age, sex, tumour histology, treatment protocol and major complications. Specific subgroup analyses comparing adenocarcinoma versus squamous cell cancer for all key outcomes were performed. Results: Overall, 3974 patients were analysed, 3083 (77.6%) male and 891 (22.4%) female; adenocarcinoma was predominant in both groups, while squamous cell cancer was observed more commonly in female patients (39.8% versus 15.1%, P < 0.001). Multivariable analysis demonstrated improved outcomes in female patients for overall survival (HRmales 1.24, 95% c.i. 1.07 to 1.44) and disease-free survival (HRmales 1.22, 95% c.i. 1.05 to 1.43), which was caused by the adenocarcinoma subgroup, whereas this difference was not confirmed in squamous cell cancer. Male patients presented higher health-related quality of life functional scores but also a higher risk of financial problems, while female patients had lower overall summary scores and more persistent gastrointestinal symptoms. Conclusion: This study reveals uniquely that female sex is associated with more favourable long-term survival after curative treatment for oesophageal cancer, especially adenocarcinoma, although long-term overall and gastrointestinal health-related quality of life are poorer in women

Association Between Physical Activity and Pancreatic Cancer Risk and Mortality: A Systematic Review and Meta-Analysis

Background: Physical activity has been associated with a lower risk of various types of cancer and reduced cancer-specific mortality. Less is known about its impact on pancreatic cancer. The aim of this systematic review and meta-analysis was to summarize evidence on the association between physical activity and pancreatic cancer risk and mortality. Methods: PubMed and Embase were searched until May 2024 for studies examining physical activity in relation to pancreatic cancer incidence and mortality. Summary risk estimates for highest vs. lowest physical activity levels were calculated using a random-effects model. The risk of publication bias was assessed with a funnel plot and Egger’s regression test. Results: A total of seven case–control and eighteen prospective cohort studies were included that investigated the association between physical activity and pancreatic cancer incidence. Our meta-analysis showed a summary estimate of 0.75 (95% CI 0.64–0.88) for case–control studies (I2 = 23%, n = 7) and a summary estimate of 0.91 (95% CI 0.86–0.97) for prospective cohort studies (I2 = 5%, n = 18). Among the six prospective cohort studies that assessed pancreatic cancer mortality, the summary estimate was 1.03 (95% CI 0.83–1.27), I2 = 50%. Conclusions: Higher levels of physical activity were associated with reduced pancreatic cancer risk. Evidence from a limited number of studies suggests that pre-diagnosis physical activity does not affect pancreatic cancer mortality

Discontinuation of neoadjuvant therapy does not influence postoperative short-term outcomes in elderly patients (≥ 70 years) with resectable gastric cancer: a population-based study from the dutch upper gastrointestinal cancer audit (DUCA) data

Background: For the elderly patients with gastric cancer, it may be more challenging to tolerate complete neoadjuvant therapy (NAT). The impact of discontinued NAT on the surgical safety and pathological outcomes of elderly patients with poor tolerance remains poorly understood. Methods: Gastric cancer patients received gastrectomy with curative intent from the Dutch upper GI cancer audit (DUCA) database were included in this study. The independent association of age with not initiating and discontinuation of NAT was assessed with restricted cubic splines (RCS). According to the RCS results, age ≥ 70 years was defined as elderly. Short-term postoperative outcomes and pathological results were compared between elderly patients who completed and discontinued NAT. Results: Between 2011- 2021, total of 3049 patients were included. The risk of not initiating NAT increased from 70 years. In 1954 (64%) patients receiving NAT, the risk of discontinuation increased from 55 years, reaching the peak around 74 years. In the elderly, discontinued NAT was not independently associated with worse 30-day mortality, overall complications, anastomotic leakage, re-intervention, and pathologic complete response, but was associated with a higher risk of R1/2 resection (p-value = 0.001), higher ypT stage (p-value = 0.004), ypN + (p-value = 0.008), and non-response ( p-value = 0.012). Conclusion: A decreased utilization of NAT has been observed in Dutch gastric cancer patients from 70 years due to old age considerations, possibly because of their high risk of discontinuation. Increasing the utilization of NAT may not adversely impact the surgical safety of gastric cancer population ≥ 70 years and may contribute to better pathological results

Cost analysis of robot-assisted versus open transthoracic esophagectomy for resectable esophageal cancer. Results of the ROBOT randomized clinical trial

Background: The previously published ROBOT trial demonstrated that robot assisted minimally invasive esophagectomy (RAMIE) is associated with a lower percentage of postoperative complications compared to open esophagectomy (OTE) for patients with esophageal cancer. The implications of these results on healthcare costs are important given the increased attention for cost-reduction in healthcare. Therefore the aim of this study was to report the hospital costs of RAMIE compared to OTE as treatment for esophageal cancer. Methods: The ROBOT trial randomized 112 patients with esophageal cancer between RAMIE and OTE through January 2012 and August 2016 in a single tertiary care academic centre in the Netherlands. The primary outcome of the current study was hospital costs from the day of esophagectomy until 90 days after discharge based on Time-Driven Activity-Based Costing methodology. Secondary outcomes included the incremental cost-effectiveness ratio per complication prevented and risk factors for increased hospital costs. Results: Of the 112 included patients, 109 patients underwent an esophagectomy, of whom 54 RAMIE and 55 OTE. The mean total hospital costs were comparable between RAMIE €40211 and OTE €39495 (mean difference €-715; bias-corrected and accelerated confidence interval € −14831 to 14783, p = 0.932). At a willingness-to-pay threshold of €20.000 to €25.000 (i.e. estimated additional costs to the hospital to treat patients with a complication) RAMIE had a probability 62%–70% of being cost effective to prevent postoperative complications. In multivariable regression analysis, major postoperative complications were the main driver of hospital costs after esophagectomy (€31839, p = 0.009). Conclusion: In this randomized trial RAMIE resulted in fewer postoperative complications compared to OTE without increasing total hospital costs