Robotic Esophagectomy. A Systematic Review with Meta-Analysis of Clinical Outcomes

Abstract

Background: Robot-Assisted Minimally Invasive Esophagectomy is demonstrated to be related with a facilitation in thoracoscopic procedure. To give an update on the state of art of robotic esophagectomy for cancr a systematic review with meta-analysis has been performed. Methods: a search of the studies comparing robotic and laparoscopic or open esophagectomy was performed trough the medical libraries, with the search string "robotic and (oesophagus OR esophagus OR esophagectomy OR oesophagectomy)". Outcomes were: postoperative complications rate (anastomotic leakage, bleeding, wound infection, pneumonia, recurrent laryngeal nerves paralysis, chylotorax, mortality), intraoperative outcomes (mean blood loss, operative time and conversion), oncologic outcomes (harvested nodes, R0 resection, recurrence) and recovery outcomes (length of hospital stay). Results: Robotic approach is superior to open surgery in terms of blood loss p = 0.001, wound infection rate, p = 0.002, pneumonia rate, p = 0.030 and mean number of harvested nodes, p < 0.0001 and R0 resection rate, p = 0.043. Similarly, robotic approach is superior to conventional laparoscopy in terms of mean number of harvested nodes, p = 0.001 pneumonia rate, p = 0.003. Conclusions: robotic surgery could be considered superior to both open surgery and conventional laparoscopy. These encouraging results should promote the diffusion of the robotic surgery, with the creation of randomized trials to overcome selection bias.

Keywords: esophageal cancer; esophagectomy; laparoscopic; open surgery; robotic.

Figure 1

PRISMA Flowchart.

Figure 2

Robotic versus laparoscopic surgery: intraoperative outcomes. (a) operative time; (b) estimated blood loss; (c) conversion.

Figure 3

Robotic versus laparoscopic surgery: postoperative complications. (a) anastomotic leakage; (b) postoperative bleeding; (c) wound infection; (d) pneumonia; (e) RLN paralysis; (f) chylothorax; (g) mortality.

Figure 3

Robotic versus laparoscopic surgery: postoperative complications. (a) anastomotic leakage; (b) postoperative bleeding; (c) wound infection; (d) pneumonia; (e) RLN paralysis; (f) chylothorax; (g) mortality.

Figure 3

Robotic versus laparoscopic surgery: postoperative complications. (a) anastomotic leakage; (b) postoperative bleeding; (c) wound infection; (d) pneumonia; (e) RLN paralysis; (f) chylothorax; (g) mortality.

Figure 4

Robotic versus laparoscopic surgery: oncologic outcomes. (a) Number of harvested nodes; (b) R0 resection.

Figure 5

Robotic versus laparoscopic surgery: length of hospital stay.

Figure 6

Robotic versus laparoscopic surgery: long-term outcomes. (a) recurrences; (b) 5-years overall survival.

Figure 7

Robotic versus open surgery: intraoperative outcomes. (a) operative time; (b) estimated blood loss.

Figure 8

Robotic versus open surgery: postoperative complications. (a) anastomotic leakage; (b) postoperative bleeding; (c) wound infection; (d) pneumonia; (e) RLN paralysis; (f) chylothorax; (g) re-operation rate; (h) mortality.

Figure 8

Robotic versus open surgery: postoperative complications. (a) anastomotic leakage; (b) postoperative bleeding; (c) wound infection; (d) pneumonia; (e) RLN paralysis; (f) chylothorax; (g) re-operation rate; (h) mortality.

Figure 8

Robotic versus open surgery: postoperative complications. (a) anastomotic leakage; (b) postoperative bleeding; (c) wound infection; (d) pneumonia; (e) RLN paralysis; (f) chylothorax; (g) re-operation rate; (h) mortality.

Figure 9

Robotic versus open surgery: oncologic outcomes. (a) number of harvested nodes; (b) R0 resection.

Figure 10

Robotic versus open surgery: length of hospital stay.

Figure 11

Robotic versus open surgery: long-term outcomes. (a) recurrences; (b) 5-years overall survival.