ASO Author Reflections: Clinical Benefit of Robot-Assisted Minimally Invasive Esophagectomy over Conventional Minimally
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Clinical Benefit of Robot-Assisted Minimally Invasive Esophagectomy over Conventional Minimally Invasive Esophagectomy Shigeru Tsunoda, MD, PhD, FACS
, and Kazutaka Obama, MD, PhD, FACS
Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
PAST Robot-assisted minimally invasive esophagectomy (RAMIE) was introduced to overcome the complexity of conventional minimally invasive esophagectomy (MIE) in the early 2000s.1 In a recent randomized controlled trial (ROBOT trial),2 RAMIE showed better short-term outcomes than totally open esophagectomy, including a significantly lower incidence of postoperative pulmonary and cardiac complications, faster functional recovery, and better quality of life. However, the favorable outcomes of RAMIE could be ascribed primarily to the study design, which maximized the difference of surgical trauma to the right thoracic and abdominal cavity. Therefore, it remains unclear whether robotic assistance in the setting of MIE has a real clinical benefit over conventional MIE.
Clavien–Dindo grade II or higher, were 51% for RAMIE and 73% for conventional MIE (P = 0.03). The severe postoperative morbidity rates, defined as Clavien–Dindo grade III or higher, were 11% for RAMIE and 29% for conventional MIE (P = 0.04). In both cases, the differences were significant. Compared with that in conventional MIE, the incidence of recurrent laryngeal nerve palsy was more than halved in RAMIE (20% and 7%, respectively; P = 0.06). Consequently, the pulmonary complication rate of RAMIE (18%) was significantly lower than that of conventional MIE (44%; P = 0.006). In the present study, robotic precise dissection at surgeon’s discretion demonstrated clear clinical benefits over conventional MIE in the confined upper mediastinum,4 while in the ROBOT trial, the positive results were partly due to less thoracic wall trauma. Therefore, RAMIE may be a promising alternative to conventional MIE.
PRESENT FUTURE In the present study,3 165 patients with esophageal carcinoma who underwent esophagectomy were retrospectively investigated to compare the short-term outcomes between RAMIE and conventional MIE employing a 1:1 propensity score matching (n = 90). Compared with conventional MIE, RAMIE showed an equivalent R0 resection rate and a similar number of resected lymph nodes, despite having a significantly longer total and thoracic operative times. The overall postoperative morbidity rates, defined as
Ó Society of Surgical Oncology 2020 First Received: 24 July 2020 Accepted: 28 July 2020 S. Tsunoda, MD, PhD, FACS e-mail: [email protected]
In the near future, even better clinical outcomes will be provided to patients undergoing esophagectomy owing to the upcoming refinement of surgical robot systems, such as the use of smaller instruments that cause less trauma in the thoracic wall, increased degrees of freedom of robotic arms for unrestricted movement, or haptic feedback and navigation technologies for a surgeon-friendly interface.
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