Robotic esophagectomy: Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer – a randomized controlled trial

Abstract

Background: The standard curative treatment for patients with esophageal cancer is perioperative chemotherapy or preoperative chemoradiotherapy followed by open transthoracic esophagectomy (OTE). Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy (RAMIE) may reduce complications and improve functional recovery.

Methods: A single center randomized controlled trial was conducted, assigning 112 patients with resectable intrathoracic esophageal cancer to either RAMIE or OTE. The composite primary endpoint was the occurrence of overall surgery-related postoperative complications (modified Clavien–Dindo classification (MCDC) grade 2-5).

Results: Overall surgery-related postoperative complications occurred less frequently after RAMIE (59%) compared to OTE (80%) (risk ratio with RAMIE (RR) 0.74 (95% Confidence interval (CI), 0.57-0.96; P=0.02). RAMIE resulted in less median blood loss (400ml versus 568ml, P<0.001), a lower percentage of pulmonary complications (RR 0.54 (95%CI, 0.34-0.85; P=0.005) and cardiac complications (RR 0.47 (95%CI, 0.27-0.83; P=0.006)) and lower mean postoperative pain (visual analogue scale, 1.86 versus 2.62; p<0.001) compared to OTE. Functional recovery at postoperative day 14 was better in the RAMIE group (RR 1.48 (95%CI, 1.03–2.13; P=0.038)) with better quality of life score at discharge (mean difference quality of life score 13.4 (2.0-24.7, p=0.02) and 6 weeks post-discharge (mean difference 11.1 quality of life score (1.0-21.1; p=0.03)). Short and long-term oncological were comparable at a medium follow up of 40 months.

Conclusions: RAMIE resulted in a lower percentage of overall, surgery-related and cardiopulmonary complications with lower postoperative pain, better short-term quality of life and a better short-term postoperative functional recovery compared to OTE. Oncological outcomes were  equal and in concordance with the highest standards nowadays. This randomized controlled trial provides evidence for the use of RAMIE to improve postoperative outcome in patients with resectable esophageal cancer.