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Objective: Finding of a significant replaced left hepatic artery (RLHA) during esophagectomy is relatively rare, with an incidence of approximately 5%. Sparing of the artery may be required to avoid complications of liver ischemia. Robotic assistance during esophagectomy may provide a technically superior method of artery preservation with minimally invasive approaches., Methods: This is a retrospective case series of patients undergoing robotic-assisted minimally invasive esophagectomy (RAMIE) identified to have a significant RLHA at time of surgery., Results: Five patients with a significant RLHA were identified from a series of over 100 RAMIE operations. Preservation of RLHA was accomplished in all cases without need for conversion, no intra-operative complications, and no post-operative liver dysfunction. The stomach was suitable and used for conduit reconstruction in all patients., Conclusions: Sparing of the RLHA during RAMIE is feasible and effective. The robotic assisted approach may obviate the need for open conversion during these complex minimally invasive operations., (Copyright © 2017 John Wiley & Sons, Ltd.)

Background: We have previously described our technique of robotic-assisted giant paraesophageal hernia repair (RA-GPEHR). The purpose of this study was to report our initial experience, early outcomes and learning curve with RA-GPEHR using a four-arm robotic platform., Methods: 24 consecutive patients presenting with symptomatic giant paraesophageal hernias (GPEH) underwent RA-GPEHR from April 2011 to February 2014. Peri-operative data and short-term patient outcomes were assessed by retrospective review of a prospectively maintained database., Results: Median age was 62 years (range 44-84). 15 (63%) patients underwent fundoplication and 9 (37%) gastropexy. Median procedure time was 277 min (range: 185-485) and decreased steadily over the experience. There were no intra-operative complications or surgical mortality. No patients experienced dysphagia in the early post-operative period., Conclusions: RA-GPEHR is safe, with reported short-term operative and functional outcomes similar to conventional laparoscopic approaches. The initial learning curve appears relatively short for experienced minimally invasive esophageal surgeons. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Background: In the seventh edition of the American Joint Committee on Cancer (AJCC) staging system for esophageal cancer, tumor grade was introduced as an independent determinant of stage grouping in early stage tumors. With the significantly lower prognosis for poorly differentiated early stage adenocarcinomas, patients with these tumors may become candidates for neoadjuvant therapy given an accurate identification of these tumors with preoperative staging. The objective of the current study was to investigate the accuracy of preoperative histopathologic grading and the effect of preoperative grade on tumor stage/prognostic grouping., Methods: Preoperative tumor grade was compared with postoperative tumor grade in 427 patients who underwent surgery without receiving neoadjuvant therapy for adenocarcinoma of the esophagus. The impact of preoperative tumor grade on stage/prognostic grouping was investigated., Results: The overall accuracy of preoperative tumor grade assessment was 76% when unknown differentiation was regarded as well/moderately differentiated as recommended by the AJCC, whereas accuracy was 73% after the exclusion of tumors with unknown grade. In patients who have tumors classified as T1 or T2 and lymph node-negative (N0) (T1-T2N0) disease, 16% were assigned to a lower stage group based on preoperative pathology, whereas 5% were assigned to a higher stage group. In the T1-T2N0 group, sensitivity for detecting a poorly differentiated tumor was 0.43 (95% confidence interval [CI], 0.30-0.56), whereas specificity was 0.94 (95% CI, 0.90-0.98)., Conclusions: With increasing use of neoadjuvant therapy, the accuracy of preoperative biopsy assessment has become increasingly important. In the current study, the accuracy of preoperative tumor grade assessment was 73%, leading to changes in AJCC stage/prognostic group in 21% of patients with T1-T2N0 esophageal adenocarcinomas. The authors concluded that caution should be exhibited in staging patients with esophageal adenocarcinoma based on preoperative biopsy data., (Copyright © 2011 American Cancer Society.)