Management of anastomotic leakage after robot-assisted minimally invasive esophagectomy with an intrathoracic anastomosis.

Anastomotic leakage is a feared complication after esophagectomy and associated with increased post-operative morbidity and mrotality. The aim of this study was to evaluate the management of leakage after robot-assisted minimally invasive esophagectomy (RAMIE) with intrathoracic anastomosis. From a single center prospectively maintained database, all patients with anastomotic leakages defined by the Esophageal Complications Consensus Group between 2016 and 2021 were included. Contained leakage was defined as presence of air or fluid at level of the anastomosis without the involvement of the mediastinum or thorax. Non-contained leakage was defined as mediastinitis and/or mediastinal/pleural fluid collections. The primary outcome was 90-day mortality and the secondary outcome was successful recovery. In this study, 40 patients with anastomotic leakage were included. The 90-day mortality rate was 3% (n = 1). Leakage was considered contained in 29 patients (73%) and non-contained in 11 patients (27%). In the contained group, the majority of the patients were treated non-surgically (n = 27, 93%) and management was successful in 22 patients (76%). In the non-contained group, all patients required a reoperation with thoracic drainage and management was successful in seven patients (64%). Management failed in 11 patients (28%) of whom 7 developed an esophagobronchial fistula, 3 had a disconnection of the anastomosis and 1 died of a septic bleeding. In conclusion, this study demonstrates that the management anastomotic leakage in patients who underwent RAMIE with an intrathoracic anastomosis was successful in 73% of the patients with a 90-day mortality rate of 3%. A differentiated approach for the management of intrathoracic anastomotic leakage is proposed.

Robot-assisted minimally invasive thoracolaparoscopic esophagectomy versus open esophagectomy: long-term follow-up of a randomized clinical trial.

Initial results of the ROBOT, which randomized between robot-assisted minimally invasive esophagectomy (RAMIE) and open transthoracic esophagectomy (OTE), showed significantly better short-term postoperative outcomes in favor of RAMIE. However, it is not yet clarified if RAMIE is equivalent to OTE regarding long-term outcomes. The aim of this study was to report the long-term oncological results of the ROBOT trial in terms of survival and disease-free survival. This study is a follow-up study of the ROBOT trial, which was a randomized controlled trial comparing RAMIE to OTE in 112 patients with intrathoracic esophageal cancer. Both the trial protocol and short-term results were previously published. The primary outcome of the current study was 5-year overall survival. Secondary outcomes were disease-free survival and recurrence patterns. Analysis was by intention to treat. During the recruitment period, 109 patients were included in the survival analysis (RAMIE n = 54, OTE n = 55). Majority of patients had clinical stage III or IV (RAMIE 63%, OTE 55%) and received neoadjuvant chemoradiotherapy (80%). Median follow-up was 60 months (range 31-60). The combined 5-year overall survival rates for RAMIE and OTE were 41% (95% CI 27-55) and 40% (95% CI 26-53), respectively (log rank test P = 0.827). The 5-year disease-free survival rate was 42% (95% CI 28-55) in the RAMIE group and 43% (95% CI 29-57) in the OTE group (log rank test P = 0.749). Out of 104 patients, 57 (55%) developed recurrent disease detected at a median of 10 months (range 0-56) after surgery. No statistically difference in recurrence rate nor recurrence pattern was observed between both groups. Overall survival and disease-free survival of RAMIE are comparable to OTE. These results continue to support the use of robotic surgery for esophageal cancer.

Robot-assisted Minimally Invasive Thoracolaparoscopic Esophagectomy Versus Open Transthoracic Esophagectomy for Resectable Esophageal Cancer: A Randomized Controlled Trial.

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 thoracolaparoscopic esophagectomy (RAMIE) may reduce complications. METHODS: A single-center randomized controlled trial was conducted, assigning 112 patients with resectable intrathoracic esophageal cancer to either RAMIE or OTE. The primary endpoint was the occurrence of overall surgery-related postoperative complications (modified Clavien-Dindo classification 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 (400 vs 568 mL, 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 analog scale, 1.86 vs 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 postdischarge [mean difference 11.1 quality of life score (1.0-21.1; P = 0.03)]. Short- and long-term oncological outcomes 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 comparable and in concordance with the highest standards nowadays.

Intermittent pneumatic compression in combination with low-molecular weight heparin in the prevention of venous thromboembolic events in esophageal cancer surgery.

INTRODUCTION: Aim of this study was to evaluate the use of Intermittent Pneumatic Compression (IPC) in the prevention of symptomatic venous thromboembolic events (VTE) in patients undergoing esophagectomy for cancer. METHODS: From a prospective database, all patients operated between 2010 and 2014 received IPC in addition to LMWH and were compared to a historical cohort of patients treated LMWH only (2004-2009). RESULTS: Of the 313 included patients, 195 (62%) received IPC. Patients with IPC received neoadjuvant chemoradiation more often (45% vs. 3%, P < 0.001), whereas, neoadjuvant chemotherapy was equally distributed (31% vs. 34%, P = 0.631). There were no differences with regard to surgical approach, operative time, blood loss, and ICU stay. Patients treated without IPC had a longer hospital stay (18 vs. 15 days, P = 0.014). Overall, 12 clinical VTE's occurred in 11 patients, which consisted of two deep venous thromboses and 10 pulmonary embolisms. In the group of patients, who received IPC 1.5% developed a symptomatic VTE compared to 6.8% in patients without IPC (OR = 0.215; 95% CI = 0.06-0.83). Multivariate analysis identified IPC as the only independent prognostic factor correlated with a reduction in postoperative VTE's (OR = 0.225; 95% CI = 0.06-0.88). CONCLUSION: The addition of IPC in patients undergoing esophagectomy for cancer was associated with a reduction in symptomatic VTE's. J. Surg. Oncol. 2017;115:181-185. © 2017 Wiley Periodicals, Inc.

Perioperative chemotherapy versus neoadjuvant chemoradiotherapy for esophageal or GEJ adenocarcinoma: A propensity score-matched analysis comparing toxicity, pathologic outcome, and survival.

OBJECTIVES: To evaluate toxicity, pathologic outcome, and survival after perioperative chemotherapy (pCT) compared to neoadjuvant chemoradiotherapy (nCRT) followed by surgery for patients with resectable esophageal or gastroesophageal junction (GEJ) adenocarcinoma. METHODS: Consecutive patients with resectable esophageal or GEJ adenocarcinoma who underwent pCT (epirubicin, cisplatin, and capecitabine) or nCRT (paclitaxel, carboplatin, and 41.4 Gy) followed by surgery in a tertiary referral center in the Netherlands were compared. Propensity score matching was applied to create comparable groups. RESULTS: Of 193 eligible patients, 21 were discarded after propensity score matching; 86 and 86 patients who underwent pCT and nCRT, respectively, remained. Grade ≥3 thromboembolic events occurred only in the pCT group (19% vs. 0%, P < 0.001), whereas grade ≥3 leukopenia occurred more frequently in the nCRT group (14% vs. 4%, P = 0.015). No significant differences regarding postoperative morbidity and mortality were found. Pathologic complete response was more frequently observed with nCRT (18% vs. 11%, P < 0.001), without significantly improving radicality rates (95% vs. 89%, P = 0.149). Both strategies resulted in comparable 3-year progression-free survival (pCT vs. nCRT: 46% vs. 55%, P = 0.344) and overall survival rates (49% vs. 50%, P = 0.934). At 3-year follow-up, fewer locoregional disease progression occurred in the nCRT group (19% vs. 37%, P = 0.024). CONCLUSIONS: Compared to perioperative chemotherapy, neoadjuvant chemoradiotherapy achieves higher pathologic response rates and a lower risk of locoregional disease progression, without improving survival.

Preserving the pulmonary vagus nerve branches during thoracoscopic esophagectomy.

BACKGROUND: Pulmonary vagus branches are transected as part of a transthoracic esophagectomy and lymphadenectomy for cancer. This may contribute to the development of postoperative pulmonary complications. Studies in which sparing of the pulmonary vagus nerve branches during thoracoscopic esophagectomy is investigated are lacking. Therefore, this study aimed to determine the feasibility and pitfalls of sparing pulmonary vagus nerve branches during thoracoscopic esophagectomy. METHODS: In 10 human cadavers, a thoracoscopic esophagectomy was performed while sparing the pulmonary vagus nerve branches. The number of intact nerve branches, their distribution over the lung lobes and the number and location of the remaining lymph nodes in the relevant esophageal lymph node stations (7, 10R and 10L) were recorded during microscopic dissection. RESULTS: A median of 9 (range 5-16) right pulmonary vagus nerve branches were spared, of which 4 (0-12) coursed to the right middle/inferior lung lobe. On the left side, 10 (3-12) vagus nerve branches were spared, of which 4 (2-10) coursed to the inferior lobe. In 8 cases, lymph nodes were left behind, at stations 10R and 10L while sparing the vagus nerve branches. Lymph nodes at station 7 were always removed. CONCLUSIONS: Sparing of pulmonary vagus nerve branches during thoracoscopic esophagectomy is feasible. Extra care should be given to the dissection of peribronchial lymph nodes, station 10R and 10L.

A new clinical scoring system to define pneumonia following esophagectomy for cancer.

BACKGROUND: Pneumonia is a frequently observed complication following esophagectomy. The lack of a uniform definition of pneumonia leads to large variations of pneumonia rates in literature. This study was designed to develop a scoring system for diagnosing pneumonia following esophagectomy at the hospital ward. METHODS: In a prospective cohort study of esophagectomy patients, known risk factors for pneumonia, temperature, leukocyte count, pulmonary radiography and sputum culture added were evaluated. Primary outcome was defined as the decision to treat suspected pneumonia. Multivariate Cox regression analysis with backward selection was used to identify predictors of pneumonia treatment. RESULTS: The majority of postoperative pneumonia treatments (88.2%) occurred at the hospital ward, where treatment was observed in 67 (36.2%) of 185 patients. Independent diagnostic determinants for pneumonia treatment were temperature (hazard ratio (HR) = 1.283, p = 0.073), leukocyte count (HR = 1.040, p = 0.078) and pulmonary radiography (HR >11.0, p = 0.000). Sputum culture did not influence the decision to treat pneumonia. These findings were used to develop a scoring system which includes temperature, leukocyte count and pulmonary radiography. CONCLUSION: The decision to treat pneumonia is based on temperature, leukocyte count and pulmonary radiography findings. The proposed clinical scoring system for pneumonia following esophagectomy at the hospital ward has the potential to aid clinical practice and improve comparability of future research in esophageal cancer surgery.

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.

Risk of thromboembolic events after perioperative chemotherapy versus surgery alone for esophageal adenocarcinoma.

BACKGROUND: Major oncologic surgery is associated with a high incidence of thromboembolic events (TEE). Addition of perioperative chemotherapy in esophageal cancer surgery may increase the risk of TEE. METHODS: The thromboembolic toxicity profile was analyzed in patients with esophageal adenocarcinoma (EAC). Two groups were identified: patients who underwent esophagectomy and received perioperative chemotherapy with epirubicin, cisplatin, and capecitabine (ECC; n = 52), and patients who were treated with surgery alone (n = 35). RESULTS: A total of 22 TEEs was observed in 17 patients (32.7%) in the chemotherapy group and 3 patients (7.5%) in the surgery-alone group (P < .01). The relative risk of developing a TEE for patients receiving perioperative chemotherapy during the whole treatment period was 3.8 (95% confidence interval 1.2-12.0). A preoperatively occurring TEE did not increase the risk of postoperative TEE, nor did it increase postoperative hospital stay (P = .325). Median postoperative hospital stay was 23 days (range 14-78) for patients with a postoperative TEE and 15 days (range 10-105) for patients without TEE (P = .126). Perioperative chemotherapy with the epirubicin, cisplatin, and capecitabine regimen was independently associated with the development of TEE in the combined preoperative and postoperative period (P = .034). CONCLUSIONS: Perioperative chemotherapy improves survival for operable esophageal cancer but comes at the price of toxicity. Perioperative chemotherapy for EAC increases the risk of TEE. However, chemotherapy-related preoperative TEE did not increase the risk of postoperative TEE, nor did it increase postoperative hospital stay, justifying its use in clinical practice.

Detecting Interval Distant Metastases With 18F-FDG PET/CT After Neoadjuvant Chemoradiotherapy for Locally Advanced Esophageal Cancer.

PURPOSE: Patients with esophageal cancer can develop distant metastases between the start of neoadjuvant chemoradiotherapy (nCRT) and planned surgery (ie, interval distant metastases). 18F-FDG PET/CT restaging after nCRT detects interval distant metastases in ~8% of patients. This study aimed to identify patients for whom 18F-FDG PET/CT restaging after nCRT could be omitted using an existing prediction model predicting for interval distant metastases or by using clinical stage groups. PATIENTS AND METHODS: Patients with locally advanced esophageal cancer who underwent baseline and restaging 18F-FDG PET/CT, nCRT, and were planned for esophagectomy between 2017 and 2021 were eligible for inclusion in this retrospective study. The primary outcome was the existing model's external performance (ie, discrimination and calibration) for predicting interval distant metastases. The existing model predictors included tumor length, cN status, squamous cell carcinoma histology, and baseline SUVmax. The secondary outcome determined the clinical stage groups (AJCC/UICC eighth edition) for adenocarcinoma and squamous cell carcinoma for which the incidence of interval distant metastases was <10%. RESULTS: In total, 127 patients were included, of whom 17 patients developed interval distant metastases (13%; 95% confidence interval [CI], 8%-21%) and 9 patients were deemed to have false-positive lesions on 18F-FDG PET/CT (7%; 95% CI, 2%-11%). Applying the existing model to this cohort yielded a discriminatory c-statistic of 0.56 (95% CI, 0.40-0.72). The calibration of the existing model was poor (ie, mostly underestimating the actual risk). The incidence of true-positive versus false-positive interval distant metastases for patients with clinical stage II disease was 5% versus 0%; clinical stage III, 14% versus 8%; and clinical stage IVa, 22% versus 9%. CONCLUSIONS: The existing prediction model cannot reliably identify patients at risk for developing interval distant metastases after nCRT for esophageal cancer. Omission of 18F-FDG PET/CT restaging after nCRT could be considered in patients with clinical stage II esophageal cancer.

Wireless Remote Home Monitoring of Vital Signs in Patients Discharged Early After Esophagectomy: Observational Feasibility Study.

BACKGROUND: Hospital stays after major surgery are shorter than ever before. Although enhanced recovery and early discharge have many benefits, some complications will now first manifest themselves in home settings. Remote patient monitoring with wearable sensors in the first days after hospital discharge may capture clinical deterioration earlier but is largely uncharted territory. OBJECTIVE: This study aimed to assess the technical feasibility of patients, discharged after esophagectomy, being remotely monitored at home with a wireless patch sensor and the experiences of these patients. In addition, we determined whether observing vital signs with a wireless patch sensor influences clinical decision making. METHODS: In an observational feasibility study, vital signs of patients were monitored with a wearable patch sensor (VitalPatch, VitalConnect Inc) during the first 7 days at home after esophagectomy and discharge from hospital. Vital signs trends were shared with the surgical team once a day, and they were asked to check the patient's condition by phone each morning. Patient experiences were evaluated with a questionnaire, and technical feasibility was analyzed on a daily basis as the percentage of data loss and gap durations. In addition, the number of patients for whom a change in clinical decision was made based on the results of remote vital signs monitoring at home was assessed. RESULTS: Patients (N=20) completed 7 days each of home monitoring with the wearable patch sensor. Each of the patients had good recovery at home, and remotely observed vital signs trends did not alter clinical decision making. Patients appreciated that surgeons checked their vital signs daily (mean 4.4/5) and were happy to be called by the surgical team each day (mean 4.5/5). Wearability of the patch was high (mean 4.4/5), and no reports of skin irritation were mentioned. Overall data loss of vital signs measurements at home was 25%; both data loss and gap duration varied considerably among patients. CONCLUSIONS: Remote monitoring of vital signs combined with telephone support from the surgical team was feasible and well perceived by all patients. Future studies need to evaluate the impact of home monitoring on patient outcome as well as the cost-effectiveness of this new approach.

Extended thoracic lymph node dissection in robotic-assisted minimal invasive esophagectomy (RAMIE) for patients with superior mediastinal lymph node metastasis.

BACKGROUND: Robot-assisted surgery may have a role in improving oncological outcomes in esophagectomy. Especially in the anatomical areas in the chest that are more difficult to reach in open surgery (including the superior mediastinum). The dexterity of the robotic instruments aid in performing a more extensive nodal dissection and the precision and detailed vision of the robotic system potentially improves staging, oncological outcomes and reduces complications (i.e., recurrent nerve palsy). In this article, we describe our experience and clinical outcomes in patients treated by robot assisted minimal invasive esophagectomy (RAMIE) in cN+ esophageal cancer patients with positive nodes localized in the superior mediastinum. METHODS: From May 2007-2018, all patients who had involved nodes by either fluor-18-deoxyglucose positron-emission-tomography-computed tomography (FDG-PET-CT) or endoscopic ultrasound (EUS) + fine needle aspiration (FNA) localized in the superior mediastinum (above level Th4/sternal angle) were identified. Patient characteristics, perioperative data, postoperative clinical outcomes/complications and overall survival were prospectively recorded and retrospectively evaluated. RESULTS: Forty patients (48% adenocarcinoma) met our inclusion criteria. All patients underwent a three-stage procedure with cervical anastomosis and 90% of the patients underwent neoadjuvant chemoradiotherapy. Mortality occurred in three patients (7.5%), of which two were caused by severe acute respiratory distress syndrome (ARDS). The most frequent complications were pneumonia (25%), chylothorax (20%), anastomotic leakage (17.5%) and vocal cord paralysis (17.5%) which was grade 1 in 72% of the patients. Radicality rate (R0 resection) was 98% and the average lymph node yield was 24 (range, 9-57). Median overall and disease-free survival was 26 and 17 months, respectively. CONCLUSIONS: RAMIE for esophageal cancer patients with node positive disease in the superior mediastinum is associated with increased mortality/morbidity. Oncological outcome showed excellent lymph node yield, R0 rate and survival was equal compared to patients with lower mediastinal node positive disease.

Robot-assisted minimally invasive esophagectomy (RAMIE) improves perioperative outcomes: a review.

Robotic assisted minimal invasive esophagectomy (RAMIE) is increasingly applied as a clinically and oncologically safe technique in the surgical treatment of esophageal cancer. This review focuses on the advantages and potential opportunities of RAMIE to improve the perioperative and oncological outcomes based on the evidence from current literature. In addition, critical notes on aspects such as procedure duration and costs are addressed in this paper.

Surgical robotics for esophageal cancer.

We present an update on robotic techniques and their advantages and use in esophageal cancer surgery. Recent work has shown tremendous progress in robotic-assisted minimally invasive esophagectomy (RAMIE) and lymphadenectomy for esophageal cancer, as well as benefits of robotic surgery in high upper esophageal tumors and T4b disease. We discuss the different RAMIE techniques, especially for intrathoracic anastomosis. The ongoing ROBOT trial had demonstrated superiority of robotic esophageal cancer surgery over open esophagectomy. There are various putative technical advantages of RAMIE over minimally invasive esophagectomy, which need to be proven in future trials.

Learning Curve for Robot-Assisted Minimally Invasive Thoracoscopic Esophagectomy: Results From 312 Cases.

BACKGROUND: Thoracic laparoscopic robot-assisted minimally invasive esophagectomy (RAMIE) was developed in 2003. RAMIE was shown to be safe and oncologically effective. The aim of this study was to assess the learning curve and the proctoring program for a newly introduced surgeon (surgeon 2). METHODS: The "learning curve" was defined as the number of operations that must be performed by a surgeon to achieve a steady level of performance. Measures of proficiency to describe the learning curve of the proctor and the newly introduced surgeon 2 included operating time, blood loss, and conversion rates and were analyzed using the cumulative sum method. Results of the newly introduced surgeon were compared with the proctor in the same period of time. RESULTS: The proctor performed 232 of 312 procedures (74%) and surgeon 2 performed 80 of 312 procedures (26%). The proctor reached proficiency after 70 procedures in 55 months. The structured proctoring program for surgeon 2 started with 20 procedures as assisting table surgeon, followed by 5 observational and 15 supervised cases. Surgeon 2 performed at the same level as the proctor concerning operating time, blood loss, conversion rates, radicality, and complications. For surgeon 2, the learning phase of thoracic laparoscopic RAMIE was completed within 24 cases (15 supervised and 9 independent cases) in 13 months; a reduction of 66% in the number of operations and a reduction of 76% in time, compared with the proctor. CONCLUSIONS: The learning phase of thoracic laparoscopic RAMIE consisted of 70 procedures in 55 months. A structured proctoring for RAMIE substantially reduced the number of procedures and time required to achieve proficiency.

Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy for esophageal cancer in the upper mediastinum.

BACKGROUND: Patients with upper third esophageal cancer or esophageal cancer with upper mediastinal paratracheal lymph node metastases are often precluded from surgery because of technical difficulties. With the aid of robotic surgery, an excellent overview and reach of the thoracic inlet can be accomplished. In this way, patients with upper mediastinal esophageal cancer are eligible for esophageal resection with curative intent. The aim of this study was to review the results of a consecutive series of patients who underwent robot-assisted minimally invasive esophagectomy (RAMIE) for tumors of the upper 1/3 of the esophagus or positive lymph nodes in the upper mediastinum. METHODS: Between 2007-2016, 31 patients who underwent RAMIE in the UMC Utrecht for proximal esophageal cancer or proximal thoracic lymphadenopathy were identified from a prospective surgical database. Perioperative characteristics and oncologic outcomes were collected. RESULTS: The majority of patients had a squamous cell carcinoma. Clinical tumor stage was cT3 or higher in 25 (81%) of patients. Clinically positive lymph nodes (cN1-3) were observed in 29 (94%) patients. Neoadjuvant treatment was administered in 27 (87%) patients. Median duration of the surgical procedure was 435 min (range 299-874 min). Pulmonary complications were most frequent and occurred in 13 (42%) patients. Median intensive care (ICU stay) was 1 day (range 1-65 days) and median overall postoperative hospital stay was 15 days (range 10-118 days). In hospital mortality was 10%. Causes of mortality were tracheo-neo-esophageal fistula, sepsis after abdominal wall drainage due to leakage of the jejunal fistula resulting in respiratory and kidney failure, after which refraining further treatment resulting in death, and irreversible ARDS in a patient with COPD Gold III needing extracorporeal life support. Radical resection was achieved in 30 (97%) of the patients. Median number of retrieved lymph nodes was 22 (range 9-57). Median time of follow up was 18 months (range 3-81 months). Median disease-free survival was 13 months (range 0-81 months) and median overall survival was 16 months (range 0-81 months). Tumor recurrence occurred in 15 patients (48%) and was locoregional only in 3 patients, systemic only in 5 patients and combined locoregional and systemic in 7 patients. CONCLUSIONS: Robot assisted thoraco-laparoscopic esophagectomy with curative intent in patients with upper mediastinal esophageal cancer is feasible, but associated with increased in hospital mortality. Short-term oncologic results are encouraging.

Current treatment options for esophageal diseases.

Exciting new developments-pharmacologic, endoscopic, and surgical-have arisen for the treatment of many esophageal diseases. Refractory gastroesophageal reflux disease presents a therapeutic challenge, and several new options have been proposed to overcome an insufficient effectiveness of proton pump inhibitors. In patients with distal esophageal spasm, drugs and endoscopic treatments are the current mainstays of the therapeutic approach. Treatment with proton pump inhibitors (or antireflux surgery) should be considered in patients with Barrett's esophagus, since a recent meta-analysis demonstrated a 71% reduction in risk of neoplastic progression. Endoscopic resection combined with radiofrequency ablation is the standard of care in patients with early esophageal adenocarcinoma. Mucosal squamous cancer may also be treated endoscopically, preferably with endoscopic submucosal dissection. Patients with upper esophageal cancer often refrain from surgery. Robot-assisted, thoracolaparoscopic, minimally invasive esophagectomy may be an appropriate option for these patients, as the robot facilitates a good overview of the upper mediastinum. Induction chemoradiotherapy is currently considered as standard treatment for patients with advanced squamous cell carcinoma, while the role of neoadjuvant therapy for adenocarcinoma remains controversial. A system for defining and recording perioperative complications associated with esophagectomy has been recently developed and may help to find predictors of mortality and morbidity.

Robotic Single-Port Laparoscopic Cholecystectomy Is Safe but Faces Technical Challenges.

BACKGROUND: For cholecystectomy, multiport laparoscopy is the recommended surgical approach. Single-port laparoscopy (SPL) was introduced to reduce postoperative pain and provide better cosmetic results, but has technical disadvantages. Robotic SPL (RSPL) was developed to overcome these disadvantages. In this prospective study, we aim to describe intraoperative results and postoperative outcomes of RSPL cholecystectomies and evaluate technical aspects of the technique. METHODS: A prospective database of all patients who underwent a RSPL cholecystectomy between January 2012 and December 2014 was analyzed. Intraoperative results and postoperative complications were evaluated. RESULTS: A total of 27 patients underwent RSPL cholecystectomy. Median age was 59 (20-78) years and median body mass index was 25 (19-35) kg/m2. The majority of patients had American Society of Anesthesiologists (ASA) II classification (67%) and 89% underwent surgery for cholecystolithiasis or cholecystitis. The median operating time was 81 (41-115) minutes. Conversion to a multiport procedure occurred in 2; one due to insufficient length of the robotic instruments. In the second and third patients, conversion to an open procedure was necessary due to inadequate exposure caused by liver cirrhosis and purulent ascites, respectively. In seven procedures, spill occurred due to rupture of the gallbladder. Postoperative complications occurred in 4 patients, including 1 bleeding (no reintervention), 1 peritonitis, and 2 wound infections. After a median follow-up of 33 (10-44) months, 5 (19%) trocar-site hernias were seen. CONCLUSION: RSPL cholecystectomy is feasible, however, encountered by technical challenges due to inadequate length of the nonwristed robotic instruments. A high incidence of gallbladder rupture and trocar-site hernias may limit its application.