The Current State of Robot-Assisted Minimally Invasive Esophagectomy (RAMIE): Outcomes from the Upper GI International Robotic Association (UGIRA) Esophageal Registry

Cezanne D Kooij¹, Cas de Jongh¹, B Feike Kingma¹, Mark I van Berge Henegouwen^{2

3}, Suzanne S Gisbertz^{2

3}, Yin-Kai Chao⁴, Philip W Chiu⁵, Philippe Rouanet⁶, Anne Mourregot⁶, Arul Immanuel⁷, Tom Mala⁸, Gijs I van Boxel⁹, Nicholas C Carter⁹, Hecheng Li¹⁰, Hans F Fuchs¹¹, Christiane J Bruns¹¹, Simone Giacopuzzi¹², Jörg C Kalff¹³, Jens-Peter Hölzen¹⁴, Mazen A Juratli¹⁴, Frank Benedix¹⁵, Eric Lorenz¹⁵, Jan-Hendrik Egberts¹⁶, Jan W Haveman¹⁷, Boudewijn van Etten¹⁷, Beat P Müller¹⁸, Peter P Grimminger¹⁹, Felix Berlth¹⁹, Guillaume Piessen²⁰, Jan W van den Berg¹, Marco Milone²¹, James D Luketich²², Inderpal S Sarkaria²³, Rubens A A Sallum²⁴, Marc J van Det²⁵, Ewout A Kouwenhoven²⁵, Matthias Brüwer²⁶, Tomas Harustiak²⁷, Takahiro Kinoshita²⁸, Takeo Fujita²⁸, Hiroyuki Daiko²⁹, Zhigang Li³⁰, Jelle P Ruurda¹, Richard van Hillegersberg³¹; UGIRA Study Group

Affiliations

¹ University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands.
² Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.
³ Cancer Center Amsterdam, Amsterdam, The Netherlands.
⁴ Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan.
⁵ Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China.
⁶ Montpellier Cancer Institute, Montpellier, France.
⁷ Royal Victoria Infirmary Newcastle Upon Tyne, Newcastle upon Tyne, UK.
⁸ Department of Gastrointestinal Surgery, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
⁹ Portsmouth Hospitals NHS Trust, Portsmouth, UK.
¹⁰ Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
¹¹ University of Cologne, Cologne, Germany.
¹² University of Verona, Verona, Italy.
¹³ University Hospital of Bonn, Bonn, Germany.
¹⁴ Universitätsklinikum Münster, Münster, Germany.
¹⁵ University Hospital Magdeburg, Magdeburg, Germany.
¹⁶ Israelitisches Krankenhaus Hamburg, Hamburg, Germany.
¹⁷ University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
¹⁸ University Digestive Healthcare, Basel, Switzerland.
¹⁹ University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
²⁰ Univ. Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France.
²¹ "Federico II" University of Naples, Naples, Italy.
²² University Pittsburgh Medical Center, Pittsburgh, PA, USA.
²³ University of Texas Southwestern Medical Center, Dallas, TX, USA.
²⁴ University of São Paulo, São Paulo, Brazil.
²⁵ ZGT Almelo, Almelo, The Netherlands.
²⁶ St. Franziskus Hospital, Münster, Germany.
²⁷ Motol University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic.
²⁸ National Cancer Center Hospital East, Chiba, Japan.
²⁹ National Cancer Center Hospital, Tokyo, Japan.
³⁰ Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
³¹ University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands. R.vanHillegersberg@umcutrecht.nl.

PMID: 39496901
PMCID: PMC11698755
DOI: 10.1245/s10434-024-16364-9

The Current State of Robot-Assisted Minimally Invasive Esophagectomy (RAMIE): Outcomes from the Upper GI International Robotic Association (UGIRA) Esophageal Registry

Cezanne D Kooij et al. Ann Surg Oncol. 2025 Feb.

. 2025 Feb;32(2):823-833.

doi: 10.1245/s10434-024-16364-9. Epub 2024 Nov 4.

Authors

Affiliations

¹ University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands.
² Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.
³ Cancer Center Amsterdam, Amsterdam, The Netherlands.
⁴ Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan.
⁵ Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China.
⁶ Montpellier Cancer Institute, Montpellier, France.
⁷ Royal Victoria Infirmary Newcastle Upon Tyne, Newcastle upon Tyne, UK.
⁸ Department of Gastrointestinal Surgery, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
⁹ Portsmouth Hospitals NHS Trust, Portsmouth, UK.
¹⁰ Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
¹¹ University of Cologne, Cologne, Germany.
¹² University of Verona, Verona, Italy.
¹³ University Hospital of Bonn, Bonn, Germany.
¹⁴ Universitätsklinikum Münster, Münster, Germany.
¹⁵ University Hospital Magdeburg, Magdeburg, Germany.
¹⁶ Israelitisches Krankenhaus Hamburg, Hamburg, Germany.
¹⁷ University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
¹⁸ University Digestive Healthcare, Basel, Switzerland.
¹⁹ University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
²⁰ Univ. Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France.
²¹ "Federico II" University of Naples, Naples, Italy.
²² University Pittsburgh Medical Center, Pittsburgh, PA, USA.
²³ University of Texas Southwestern Medical Center, Dallas, TX, USA.
²⁴ University of São Paulo, São Paulo, Brazil.
²⁵ ZGT Almelo, Almelo, The Netherlands.
²⁶ St. Franziskus Hospital, Münster, Germany.
²⁷ Motol University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic.
²⁸ National Cancer Center Hospital East, Chiba, Japan.
²⁹ National Cancer Center Hospital, Tokyo, Japan.
³⁰ Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
³¹ University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands. R.vanHillegersberg@umcutrecht.nl.

PMID: 39496901
PMCID: PMC11698755
DOI: 10.1245/s10434-024-16364-9

Abstract

Background: Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly adopted in centers worldwide, with ongoing refinements to enhance results. This study aims to assess the current state of RAMIE worldwide and to identify potential areas for improvement.

Methods: This descriptive study analyzed prospective data from esophageal cancer patients who underwent transthoracic RAMIE in Upper GI International Robotic Association (UGIRA) centers. Main endpoints included textbook outcome rate, surgical techniques, and perioperative outcomes. Analyses were performed separately for intrathoracic (Ivor-Lewis) and cervical anastomosis (McKeown), divided into three time cohorts (2016-2018, 2019-2020, 2021-2023). A sensitivity analysis was conducted with cases after the learning curve (> 70 cases).

Results: Across 28 UGIRA centers, 2012 Ivor-Lewis and 1180 McKeown procedures were performed. Over the time cohorts, textbook outcome rates were 39%, 48%, and 49% for Ivor-Lewis, and 49%, 63%, and 61% for McKeown procedures, respectively. Fully robotic procedures accounted for 66%, 51%, and 60% of Ivor-Lewis procedures, and 53%, 81%, and 66% of McKeown procedures. Lymph node yield showed 27, 30, and 30 nodes in Ivor-Lewis procedures, and 26, 26, and 34 nodes in McKeown procedures. Furthermore, high mediastinal lymphadenectomy was performed in 65%, 43%, and 37%, and 70%, 48%, and 64% of Ivor-Lewis and McKeown procedures, respectively. Anastomotic leakage rates were 22%, 22%, and 16% in Ivor-Lewis cases, and 14%, 12%, and 11% in McKeown cases. Hospital stay was 13, 14, and 13 days for Ivor-Lewis procedures, and 12, 9, and 11 days for McKeown procedures. In Ivor-Lewis and McKeown, respectively, the sensitivity analysis revealed textbook outcome rates of 43%, 54%, and 51%, and 47%, 64%, and 64%; anastomotic leakage rates of 28%, 18%, and 15%, and 13%, 11%, and 10%; and hospital stay of 11, 12, and 12 days, and 10, 9, and 9 days.

Conclusions: This study demonstrates favorable outcomes over time in achieving textbook outcome after RAMIE. Areas for improvement include a reduction of anastomotic leakage and shortening of hospital stay.

Keywords: Esophageal cancer; Minimally invasive esophagectomy; Robot-assisted esophagectomy.

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Conflict of interest statement

Disclosure: Mark van Berge Henegouwen: Consulting or advisory role: Viatris, Johnson & Johnson, BBraun, Stryker, Medtronic. Philippe Rouanet, Anne Mourregot, Gijs van Boxel, Marc van Det, Ewout A. Kouwenhoven: Consulting or advisory role: Intuitive Surgical. Peter Grimminger: Consulting or advisory role: Intuitive Surgical, Medicaroid. Guillaume Piessen: Consulting or advisory role: BMS, Nestlé, Astellas Pharma, Daiichi; travel or accommodation: Medtronic, MSD. Inderpal Sarkaria: Teaching, consulting, research grants, co-founder and/or advisory: CMR, Intuitive, Medtronic, Stryker, OTL, Activ Surgical, AMSI, VAIM, Oncolys. Takahiro Kinoshita: Honorarium for lectures for Intuitive Surgical. Jelle Ruurda: Consulting or advisory role: Intuitive Surgical, Medtronic. Richard van Hillegersberg: Consulting or advisory role: Intuitive Surgical, Medtronic, Olympus. Cas de Jongh: Research grant in 2018 for a period of 1 year to make a start with establishing the UGIRA Esophageal Registry, provided by Intuitive (this is mentioned in the manuscript). Philip Chiu: Cornerstone Robotics Co. Ltd; serves as a Board member with stock options. Nicholas Carter: Proctor for Intuitive Surgical teaching robotic surgery to other hospitals. Christiane Bruns: Advisory board, Medtronic; oral presentations, AstraZeneca; grant support, Sirtex; Editorial Board, MedUpdate; research grant, Stryker. James Luketich: Owns stock in Intuitive Surgical but this represents <5% of his investments and does not influence his research. Suzanne Gisbertz: J&J (money paid to institution, not to her personally); Medicaroid (money paid to institution, not to her personally); Olympus (money paid to institution, not to her personally). Cezanne D. Kooij, B. Feike Kingma, Yin-Kai Chao, Arul Immanuel, Tom Mala, Hecheng Li, Hans F. Fuchs, Simone Giacopuzzi, Jörg C. Kalff, Jens-Peter Hölzen, Mazen A. Juratli, Frank Benedix, Eric Lorenz, Jan-Hendrik Egberts, Jan W. Haveman, Boudewijn van Etten, Beat P. Müller, Felix Berlth, Jan W. van den Berg, Marco Milone, Rubens A.A. Sallum, Matthias Brüwer, Tomas Harustiak, Takeo Fujita, Hiroyuki Daiko, and Zhigang Li have declared no conflicts of interest that may be relevant to the contents of this study.

Figures

**Fig. 1**
Inclusion of cases into the UGIRA Esophageal Registry. Date of extraction from online data capturing tool: 31 December 2023. *UGIRA* Upper GI International Robotic Association, *RAMIE* robot-assisted minimally invasive esophagectomy, *GIST* gastrointestinal stromal tumor

**Fig. 2**
(A) Textbook outcome, (B) postoperative complications (specified for pulmonary complication and anastomotic leakage), (C) median lymph node yield, (D) R0 resection, (E) length of hospital and IC/MC stay, and (F) mortality within 30 days per time period for Ivor–Lewis (left) and McKeown (right) procedures in the whole cohort (solid line) and in the sensitivity analysis (dotted line), excluding the first 70 cases per center. Data from the UGIRA Esophageal Registry. IC intensive care, MC medium care, *UGIRA* Upper GI International Robotic Association

See this image and copyright information in PMC

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The Current State of Robot-Assisted Minimally Invasive Esophagectomy (RAMIE): Outcomes from the Upper GI International Robotic Association (UGIRA) Esophageal Registry

Affiliations

The Current State of Robot-Assisted Minimally Invasive Esophagectomy (RAMIE): Outcomes from the Upper GI International Robotic Association (UGIRA) Esophageal Registry

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

MeSH terms

LinkOut - more resources

Full Text Sources

Medical