Hybrid laparoscopic versus fully robot-assisted minimally invasive esophagectomy:an international propensity-score matched analysis of perioperative outcome

Background: Currently, little is known regarding the optimal technique for the abdominal phase of RAMIE. The aim of this study was to investigate the outcome of robot-assisted minimally invasive esophagectomy (RAMIE) in both the abdominal and thoracic phase (full RAMIE) compared to laparoscopy during the abdominal phase (hybrid laparoscopic RAMIE). Methods: This retrospective propensity-score matched analysis of the International Upper Gastrointestinal International Robotic Association (UGIRA) database included 807 RAMIE procedures with intrathoracic anastomosis between 2017 and 2021 from 23 centers. Results: After propensity-score matching, 296 hybrid laparoscopic RAMIE patients were compared to 296 full RAMIE patients. Both groups were equal regarding intraoperative blood loss (median 200 ml versus 197 ml, p = 0.6967), operational time (mean 430.3 min versus 417.7 min, p = 0.1032), conversion rate during abdominal phase (2.4% versus 1.7%, p = 0.560), radical resection (R0) rate (95.6% versus 96.3%, p = 0.8526) and total lymph node yield (mean 30.4 versus 29.5, p = 0.3834). The hybrid laparoscopic RAMIE group showed higher rates of anastomotic leakage (28.0% versus 16.6%, p = 0.001) and Clavien Dindo grade 3a or higher (45.3% versus 26.0%, p &lt; 0.001). The length of stay on intensive care unit (median 3 days versus 2 days, p = 0.0005) and in-hospital (median 15 days versus 12 days, p &lt; 0.0001) were longer for the hybrid laparoscopic RAMIE group. Conclusions: Hybrid laparoscopic RAMIE and full RAMIE were oncologically equivalent with a potential decrease of postoperative complications and shorter (intensive care) stay after full RAMIE.</p

The presence of metastatic thoracic duct lymph nodes in Western esophageal cancer patients: A Multinational Observational Study

BACKGROUND: The thoracic lymphadenectomy during an esophagectomy for esophageal cancer includes resection of the thoracic duct (TD) compartment containing the TD lymph nodes (TDLNs). The role of TD compartment resection is still a topic of debate since metastatic TDLNs have only been demonstrated in squamous cell carcinomas in Eastern esophageal cancer patients. Therefore, the aim of this study was to assess the presence and metastatic involvement of TDLNs in a Western population, in which adenocarcinoma is the predominant type of esophageal cancer. METHODS: From July 2017 to May 2020, all consecutive patients undergoing an open or robot-assisted transthoracic esophagectomy with concurrent lymphadenectomy and resection of the TD compartment in the University Medical Center Utrecht in Utrecht, the Netherlands, and the Città della Salute e della Scienza University Hospital in Turin, Italy, were included. The TD compartment was resected en bloc and was separated in the operation room by the operating surgeon after which it was macroscopically and microscopically assessed for (metastatic) TDLNs by the pathologist. RESULTS: A total of 117 patients with an adenocarcinoma (73%) or squamous cell carcinoma (27%) of the esophagus were included. In 61 (52%) patients, TDLNs were found, containing metastasis in 9 (15%) patients. No major complications related to TD compartment resection were observed. CONCLUSIONS: This study demonstrates the presence of metastatic TDLNs in adenocarcinomas of the esophagus. This result provides a valid argument to routinely extend the thoracic lymphadenectomy with resection of the TD compartment during an esophagectomy for esophageal cancer

Anastomotic leakage following robot-assisted minimally invasive esophagectomy (RAMIE): which anastomosis should be preferred?

\ua9 The Author(s) 2025.Background: The optimal technique for intrathoracic esophagogastric anastomosis in esophagectomy remains undetermined. This study evaluates different anastomotic techniques in robot-assisted minimally invasive esophagectomy (RAMIE) and their impact on anastomotic leakage rates. Materials and Methods: This observational, retrospective, comparative cohort study analyzed data obtained from the Upper GI International Robotic Association (UGIRA) Esophageal Registry. All consecutive patients with a histologically proven esophageal malignancy who underwent RAMIE with intrathoracic esophagogastrostomy were included. The anastomotic technique was performed based on the clinical judgement and expertise of each individual surgeon. For comparison, the four most common techniques were included: circular end-to-side, linear side-to-side, handsewn end-to-side, and handsewn end-to-end. The primary endpoint of this study was the occurrence of anastomotic leakage, defined by the Esophagectomy Complications Consensus Group as a full-thickness gastrointestinal defect involving the esophagus, anastomosis, staple line, or conduit, regardless of its presentation or method of identification. Results: Between 2016 and September 2023, 1518 patients were included. Univariable analysis demonstrated that the linear stapled side-to-side anastomosis was associated with the lowest anastomotic leakage rate (14.0%), while the handsewn end-to-end anastomosis had the highest (32.8%) (p &lt; 0.001). The anastomotic leakage rates for circular end-to-side and handsewn end-to-side anastomoses were 19.4% and 26.9%, respectively. Multivariable analysis confirmed that anastomotic technique was independently associated with anastomotic leakage. Specifically, handsewn anastomoses were associated with a higher risk of anastomotic leakage for both end-to-side (OR 1.675, 95% CI 1.195–2.348, p = 0.003) and end-to-end (OR 2.181, 95% CI 1.403–3.390, p &lt; 0.001) techniques compared to circular end-to-side anastomoses. Conclusions: In RAMIE, linear side-to-side and circular end-to-side stapled anastomoses are associated with lower anastomotic leakage rates compared to handsewn techniques. While acknowledging the multifactorial complexity of anastomotic leakage, these findings favor the use of mechanical stapling in clinical practice

P67 SEMIMECHANICAL ANASTOMOSIS DURING ESOPHAGECTOMY: A NEW GOLD STANDARD?

Abstract Aim The aim of this single-center retrospective study was to compare the surgical outcomes of semimechanical (SM) and totally manual (TM) anastomoses during esophagectomy regardless of the surgical access and of the type of esophageal replacement. Background and Methods Several techniques for esophageal anastomosis during esophagectomy have been described, all of which are associated with variable leakage and stricture rates. Given the significant morbidity of esophageal fistula, reducing its incidence is of paramount importance. We report our single-center experience with the semimechanical technique, as compared to the totally manual technique. 312 partial esophagectomies performed between January, 1998 and April, 2018 were analyzed. The series was split into a training period (1/1998-9/2015), when both TM and SM techniques were used, and a validation period (10/2015-4/2018), during which SM technique became standard practice. Propensity score matching was used to reduce confounding. Results The training period included 212 esophagectomies (90 TM, 122 SM); SM technique was initially used in the neck and afterwards also in the thorax, mainly with gastric conduits (92%), whereas the TM group contained a prevalence of jejunal loops (48%). SM anastomosis was associated with a significant reduction of both fistula (0.8% versus 12.2%; p&lt;0.001) and stricture rate (0% versus 6.7%; p=0.005). After propensity score matching the difference in fistula (0% versus 13.5%; p=0.013) and stricture rate (0% versus 9.6%; p=0.022) was confirmed. During the validation period, which included 100 esophagectomies performed with SM anastomosis, 1 fistula (1%) and 1 stricture (1%) were observed. Conclusions SM technique for esophageal anastomosis outperforms TM technique and allows achieving very low complications rates. </jats:sec