Robot-Assisted Minimally Invasive Esophagectomy versus Open Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-Analysis

Abstract

Robot-assisted minimally invasive esophagectomy (RAMIE) was introduced as a further development of the conventional minimally invasive esophagectomy, aiming to further improve the high morbidity and mortality associated with open esophagectomy. We aimed to compare the outcomes between RAMIE and open esophagectomy, which remains a popular approach for resectable esophageal cancer. Ten studies meeting our inclusion criteria were identified, including five retrospective cohort, four prospective cohort, and one randomized controlled trial. RAMIE was associated with significantly lower rates of overall pulmonary complications (odds ratio (OR): 0.38, 95% confidence interval (CI): [0.26, 0.56]), pneumonia (OR: 0.39, 95% CI: [0.26, 0.57]), atrial fibrillation (OR: 0.53, 95% CI: [0.29, 0.98]), and wound infections (OR: 0.20, 95% CI: [0.07, 0.57]) and resulted in less blood loss (weighted mean difference (WMD): -187.08 mL, 95% CI: [-283.81, -90.35]) and shorter hospital stays (WMD: -9.22 days, 95% CI: [-14.39, -4.06]) but longer operative times (WMD: 69.45 min, 95% CI: [34.39, 104.42]). No other statistically significant difference was observed regarding surgical and short-term oncological outcomes. Similar findings were observed when comparing totally robotic procedures only to OE. RAMIE is a safe and feasible procedure, resulting in decreased cardiopulmonary morbidity, wound infections, blood loss, and shorter hospital stays compared to open esophagectomy.

Keywords: RAMIE; minimally invasive esophagectomy; open esophagectomy; robot-assisted minimally invasive esophagectomy; robotic esophagectomy.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of the study selection process.

Figure 2

Forest plots of overall complication rate (A), overall pulmonary complication rate (B), anastomotic leakage rate (C), 30-day mortality rate (D), and 90-day mortality rate (E) [21,23,24,25,34,35,36,37,38,39,40,41].

Figure 3

Forest plots of total lymph nodes resected (A) and margin-negative resection (R0) rate (B) [21,23,34,35,37,38,39,40,41].

Figure 4

Forest plots of operative time (A), estimated blood loss (B), intensive care unit (ICU) length of stay (C), and hospital length of stay (D) [21,23,34,35,37,38,39,40,41].

Figure 5

Forest plots of pneumonia rate (A), acute respiratory distress syndrome rate (B), and atrial fibrillation rate (C) [21,23,34,35,36,37,39,41].

Figure 6

Forest plots of postoperative hemorrhage rate (A), chylothorax rate (B), recurrent laryngeal nerve palsy rate (C), and wound infection rate (D) [21,23,34,35,36,37,38,39,41].