| PART I RETROSPECTIVE ANALYSIS OF 100 ROBOT ASSISTED ESOPHAGECTOMYBACKGROUND: This study aims to report our experience in robot assisted esophagectomy(RAE)in the treatment of resectable esophageal carcinoma.METHODS: A series of 100 consecutive patients who underwent robot assisted esophagectomy from November 1,2015 to October 31,2016 in Shanghai Chest Hospital were collected and clinical data were reviewed retrospectively.Four periods were equally divided according to surgery order and the short-term outcomes of each group(25 patients)were analyzed.RESULTS: Overall,one hundred patients(77 male and 23 female)with the mean age of 63.0±7.8 years who underwent robot assisted esophagectomy were analyzed.The thoracic procedure was all successfully performed with the assistance of robot.The mean total duration was 270.3 ± 56.2 mins and the estimated blood loss was 96.9 ± 27.7 ml.R0 resection were performed in 97 patients with the mean total dissected lymph nodes of 17.6 ± 10.4 and the mean yield lymph nodes along recurrent laryngeal nerve of 4.0 ± 3.2.The median postoperative hospital stay were 12 days and no 90-day mortality was observed.The most common complication was vocal cord palsy(16%).A significant reduction of the thoracic duration after the initial 25 cases(P < 0.001).After 50 cases,the lymph nodes dissection of total,mediastinum and along the recurrent laryngeal nerve were significant improved(P < 0.001,P < 0.001,P = 0.001,respectively)with shorter postoperative hospital stay(P = 0.005).CONCLUSION: RAE is a safe and feasible alternative surgical approach for resectable esophageal carcinoma with a great yield of lymph nodes,especially along the recurrent laryngeal nerve.We assumed that surgeon will become familiar with the thoracic manipulation of robot assisted esophagectomy after 25-50 cases.PART II TOTAL ROBOT-ASSISTED THORACOSCOPIC-LAPAROSCOPIC ESOPHAGECTOMY VERSUS CONVENTIONAL MINIMALLY INVASIVE ESOPHAGECTOMY: A RETROSPECTIVE COHORT STUDY OF 249 CONSECUTIVE THORACIC ESOPHAGEAL CANCER PATIENTSBACKGROUND: Robot assisted esophagectomy(RAE)has rapidly increased during the last decade and has been shown to be a safe alternative surgical approach for esophageal carcinoma.However,the superiority and inferiority of RAE comparing to conventional thoracoscopic-laparoscopic esophagectomy(CTLE)has not been well established.This study aimed to compare the short-term outcomes between complete RAE and CTLE.METHODS: We retrospectively analyzed the clinical data from a series of 249 consecutive patients who underwent complete minimally invasive esophagectomy with Mckeown approach and two-field lymph node dissection Between November 2015 and March 2017.Of them,85 patients received RAE and CTLE were performed in the remaining 164 patients.RESULTS: The RAE and CTLE groups were comparable in terms of age,gender,body mass index(BMI),tumor location,Charlson Comorbidity Index(CCI)or neoadjuvant therapy.One patient in RAE group and six patients in CTLE group required conversions.Compared with the CTLE group,the RAE group was associated with similar total operative duration(260.4±54.1 vs 260.9±55.5 minutes,P=0.944)and thoracic operative duration(89.2±25.1 vs 94.1±33.7 minutes,P=0.195);significantly shorter ICU stay(1 vs 2 days,P=0.025)and shorter length of postoperative hospital stay(11 vs 13 days,P=0.226);less estimated blood loss(208.9±69.2 vs 242.91±75.6 ml,P=0.403).Regarding oncologic outcomes,the majority of patients in both groups had esophageal squamous cell carcinoma(83,97.6% in RAE vs 160,97.6% in CTLE,P=0.830).The R0 resection was achieved in 94.1% of RAE group and 92.7% of CTLE group.The total number of lymph nodes harvested was similar between RAE and CTLE(18.0±10.2 vs 17.5±7.6,P=0.622),but the lymph nodes dissected along the recurrent laryngeal nerve(RLN)were statistically higher in RAE group(4.4±3.4 vs 3.1±2.4,P=0.002).No surgical-related mortality was noted in either group.There were no significant differences between RAE and CTLE in the incidence of anastomotic leak(17.6% vs 15.9%,P=0.717),respiratory failure(5.9% vs 3.7%,P=0.418)or vocal cord palsy(18.8% vs 14.6%,P=0.393).CONCLUSION: We had demonstrated that RAE is a safe and feasible alternative surgical treatment for resectable esophageal carcinoma.Compared with CTLE,RAE has comparable surgical duration and morbidity but is associated with shorter postoperative hospital stay and a greater yield of lymph nodes along the recurrent laryngeal nerve.Long-term follow up is required to determine the oncologic efficiency.PART III COMPARISON OF ROBOT ASSISTED ESOPHAGECTOMY AND CONVENTIONAL THORACOSCOPIC-LAPAROSCOPIC ESOPHAGECTOMY: A MULTICENTER PROSPECTIVE PHASE III RANDOMISED CLINICAL TRIALBACKGROUND: Esophageal cancer is the most common fatal tumor in China,accounting for more than half of the world’s annual incidence.The overall 5-year survival rate is only about 25%.Surgical treatment is still the most effective treatment,the five-year survival rate can be about 40%.However,surgical related complications were reported high as more than 50%,so how to reduce surgical trauma,more radical lymph node dissection and longer-term survival has become the current problems which need to be solved.Robot-assisted minimally invasive surgery is expected to solve the above problems.Its features include minimally invasive approach,sophisticated operation,complete removal of tumor and lymph nodes and many other advantages.However,robot assisted esophagectomy is still in the exploratory stage,the international single center group reported was rare and no reports on prospective controlled study.METHODS: This study is a multicenter,prospective,randomized,parallel controlled phase III trial.The purpose of this study is to explore whether the long-term survival of robotic thoracoscopic assisted esophagectomy is not inferior to the conventional thoracoscopic assisted esophagectomy.The primary endpoint of this study was 5-year Overall Survival(OS).Secondary endpoints were 5-year Disease Free Survival(DFS),3-year OS and DFS,duration of surgery,and intraoperative blood loss,lymph node dissection,R0 resection rate,complications within 90 days,postoperative quality of life.The study is expected to include a sample size of 300 cases,150 cases in each group.RESULTS: As of January 2018,70 patients were enrolled in this study,including 36 in the experimental group(RAE group)and 34 in the control group(CTLE group).The total duration of surgery was shorter in the RAE group(217.3 vs 261.5 min,P <0.001).The chest operation time was shorter in the RAE group(74.1 vs 104.1 min,P <0.001).The amount of blood loss was less in the RAE group(188.3 vs 219.1 ml,P <0.001).There was no statistical difference between the two groups in the number of lymph node dissection,with an average of 19.The average postoperative hospital stay in both groups was 10 days.The most common complication after surgery was recurrent laryngeal nerve injury(13,18.6%).CONCLUSION: This study is a multicenter,prospective,randomized,parallel controlled phase III trial.Compared with CTLE,the surgical duration and blood loss were shorter in RAE group.Long-term follow up is required to determine the oncologic efficiency. |
