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Description Minimally invasive technologies have improved outcomes after esophagectomy and the use of robotic technology in Europe is rapidly increasing. Aim of this study is to evaluate the introduction of new technologies in a center of excellence for upper gastrointestinal surgery. Methods A standardized teaching protocol of a complete OR team was performed in simulation and animal models at the center for the future of surgery (San Diego, CA) and IRCAD (Strasbourg, France) to receive certification as console surgeons. Starting 02/2017 the davinci xi and stryker ICG laparoscopy systems were introduced at our academic center (certified center of excellence for surgery of the upper gastrointestinal tract, n > 300 esophageal cases/year). After simple training procedures based on our minimally invasive expertise were performed, difficulty was increased based on a modular step up approach to safely perform robotic thoracic assisted Ivor Lewis esophagectomy. Results From 02/2017–02/2018, a total of 35 robotic cases were performed. All cases were performed safely without operation-associated complications. Level of difficulty was increased based on our modular step up approach without quality compromises. Video documentation using the new technology is provided. Conclusion The standardized training protocol and our modular step up approach allowed safe introduction of the new technology used. All cases were performed safely without operation-associated complications. Disclosure All authors have declared no conflicts of interest. [ABSTRACT FROM AUTHOR]

Introduction: Transthoracic esophagectomy is a highly complex and sophisticated procedure with high morbidity rates and a significant mortality. Surgical access has consistently become less invasive, transitioning from open esophagectomy to hybrid esophagectomy (HE) then to totally minimally invasive esophagectomy (MIE), and most recently to robot-assisted minimally invasive esophagectomy (RAMIE), with each step demonstrating improved patient outcomes. Aim of this study with more than 600 patients is to complete a propensity-score matched comparison of postoperative short-term outcomes after highly standardized RAMIE vs. HE in a European high volume center., Patients and Methods: Six hundred and eleven patients that underwent transthoracic Ivor-Lewis esophagectomy for esophageal cancer between May 2016 and May 2021 were included in the study. In January 2019, we implemented an updated robotic standardized anastomotic technique using a circular stapler and ICG (indocyanine green) for RAMIE cases. Data were retrospectively analyzed from a prospectively maintained IRB-approved database. Outcomes of patients undergoing standardized RAMIE from January 2019 to May 2021 were compared to our overall cohort from May 2016-April 2021 (HE) after a propensity-score matching analysis was performed., Results: Six hundred and eleven patients were analyzed. 107 patients underwent RAMIE. Of these, a total of 76 patients underwent a robotic thoracic reconstruction using the updated standardized circular stapled anastomosis (RAMIE group). A total of 535 patients underwent HE (Hybrid group). Seventy patients were propensity-score matched in each group and analysis revealed no statistically significant differences in baseline characteristics. RAMIE patients had a significantly shorter ICU stay (p = 0.0218). Significantly more patients had no postoperative complications (Clavien Dindo 0) in the RAMIE group [47.1% vs. 27.1% in the HE group (p = 0.0225)]. No difference was seen in lymph node yield and R0 resection rates. Anastomotic leakage rates when matched were 14.3% in the hybrid group vs. 4.3% in the RAMIE group (p = 0.07)., Conclusion: Our analysis confirms the safety and feasibility of RAMIE and HE in a large cohort after propensity score matching. A regular postoperative course (Clavien-Dindo 0) and a shorter ICU stay were seen significantly more often after RAMIE compared to HE. Furthermore it shows that both procedures provide excellent short-term oncologic outcomes, regarding lymph node harvest and R0 resection rates. A randomized controlled trial comparing RAMIE and HE is still pending and will hopefully contribute to ongoing discussions., (© 2022. The Author(s).)

Background: Esophagectomy is a technically challenging procedure, associated with significant morbidity. The introduction of minimally invasive esophagectomy (MIE) has reduced postoperative morbidity., Objective: Although the short-term effect on complications is increasingly being recognized, the impact on long-term survival remains unclear. This study aims to investigate the association between postoperative complications following MIE and long-term survival., Methods: Data were collected from the EsoBenchmark Collaborative composed by 13 high-volume, expert centers routinely performing MIE. Patients operated between June 1, 2011 and May 31, 2016 were included. Complications were graded using the Clavien-Dindo (CD) classification. To correct for short-term effects of postoperative complications on mortality, patients who died within 90 days postoperative were excluded. Primary endpoint was 5-year overall survival., Results: A total of 915 patients were included with a mean follow-up time of 30.8 months (standard deviation 17.9). Complications occurred in 542 patients (59.2%) of which 50.2% had a CD grade ≥III complication [ie, (re)intervention, organ dysfunction, or death]. The incidence of anastomotic leakage (AL) was 135 of 915 patients (14.8%) of which 84 patients were classified as a CD grade ≥III. Multivariable analysis showed a significantly deteriorated long-term survival in all patients with AL [hazard ratio (HR) 1.68, 95% confidence interval (CI) 1.25-2.24]. This inverse relation was most distinct when AL was scored as a CD grade ≥III (HR 1.83, 95% CI 1.30-2.58). For all other complications, no significant association with long-term survival was found., Conclusion: The occurrence and severity of AL, but not overall complications, after MIE negatively affect long-term survival of esophageal cancer patients., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To investigate if prolonged TTS after completed nCRT improves postoperative outcomes for esophageal and esophagogastric junction cancer., Summary of Background Data: TTS has traditionally been 4-6 weeks after completed nCRT. However, the optimal timing is not known., Methods: A multicenter clinical trial was performed with randomized allocation of TTS of 4-6 or 10-12 weeks. The primary endpoint of this sub-study was overall postoperative complications defined as Clavien-Dindo grade II-V. Secondary endpoints included complication severity according to Clavien-Dindo grade IIIb-V, postoperative 90-day mortality, and length of hospital stay. The study was registered in Clinicaltrials.gov (NCT02415101)., Results: In total 249 patients were randomized. There were no significant differences between standard TTS and prolonged TTS with regard to overall incidence of complications Clavien-Dindo grade II-V (63.2% vs 72.6%, P = 0.134) or regarding Clavien-Dindo grade IIIb-V complications (31.6% vs 34.9%, P = 0.603). There were no statistically significant differences between standard and prolonged TTS regarding anastomotic leak (P = 0.596), conduit necrosis (P = 0.524), chyle leak (P = 0.427), pneumonia (P = 0.548), and respiratory failure (P = 0.723). In the standard TTS arm 5 patients (4.3%) died within 90 days of surgery, compared to 4 patients (3.8%) in the prolonged TTS arm (P = 1.0). Median length of hospital stay was 15 days in the standard TTS arm and 17 days in the prolonged TTS arm (P = 0.234)., Conclusion: The timing of surgery after completed nCRT for carcinoma of the esophagus or esophagogastric junction, is not of major importance with regard to short-term postoperative outcomes.

Background: Adenocarcinoma of the gastroesophageal junction (GEJ) Siewert type II can be resected by transthoracic esophagectomy or transhiatal extended gastrectomy. Both allow for a complete tumor resection, yet there is an ongoing controversy about which surgical approach is superior with regards to quality of life, oncological outcomes and survival. While some studies suggest a better oncological outcome after transthoracic esophagectomy, others favor transhiatal extended gastrectomy for a better postoperative quality of life. To date, only retrospective studies are available, showing ambiguous results., Methods: This study is a multinational, multicenter, randomized, clinical superiority trial. Patients (n = 262) with a GEJ type II tumor resectable by both transthoracic esophagectomy and transhiatal extended gastrectomy will be enrolled in the trial. Type II tumors are defined as tumors with their midpoint between ≤1 cm proximal and ≤ 2 cm distal of the top of gastric folds on preoperative endoscopy. Patients will be included in one of the participating European sites and are randomized to either transthoracic esophagectomy or transhiatal extended gastrectomy. The trial is powered to show superiority for esophagectomy with regards to the primary efficacy endpoint overall survival. Key secondary endpoints are complete resection (R0), number and localization of tumor infiltrated lymph nodes at dissection, post-operative complications, disease-free survival, quality of life and cost-effectiveness. Postoperative survival and quality of life will be followed-up for 24 months after discharge. Further survival follow-up will be conducted as quarterly phone calls up to 60 months., Discussion: To date, as level 1 evidence is lacking, there is no consensus on which surgery is superior and both surgeries are used to treat GEJ type II carcinoma worldwide. The CARDIA trial is the first randomized trial to compare transthoracic esophagectomy versus transhiatal extended gastrectomy in patients with GEJ type II tumors. Several quality control measures were implemented in the protocol to ensure data reliability and increase the trial's significance. It is hypothesized that esophagectomy allows for a higher rate of radical resections and a more complete mediastinal lymph node dissection, resulting in a longer overall survival, while still providing an acceptable quality of life and cost-effectiveness., Trial Registration: The trial was registered on August 2nd 2019 at the German Clinical Trials Register under the trial-ID DRKS00016923 .