Safe and Appropriate Minimally Invasive and Robotic Esophagectomy in a Community Cancer Center

Introduction

Minimally invasive esophagectomy (MIE) is a technically challenging procedure that has been associated with better outcomes at higher volume tertiary centers. ¹ These destination centers are limited, however, and frequently require lengthy travel for many patients to access this level of care. Louisiana is one of the most impoverished states in the United States with a disproportionate cancer burden.^2,3 In an ideal setting without financial limitations for patients, travel to a high-volume center would be commonplace. Unfortunately, the financial burden associated with travel is not simply an obstacle but a complete barrier to the best available treatment. Moreover, extensive travel for operative management and recovery places patients far from family and other support networks and can create difficulties associated with postoperative follow up as well as discharge planning/placement. Collectively, these factors impede access to the best possible care for patients with cancer.

MIE and more specifically, robotic esophagectomy has transformed the landscape of esophagectomy. Benefits well know with minimally invasive techniques such as reduced hospital stay, decreased postoperative pain, and better postoperative function have all been demonstrated in MIE. The robotic platform further offers enhanced surgeon visualization and precise dissection and tissue manipulation that is much more technically challenging laparoscopically. While robotic vs laparoscopic MIE is outside the scope of this manuscript, we recognize that this is an area of active investigation.

The ability to provide appropriate and safe care for patients requiring MIE on a community level has the potential to eliminate costly travel barriers to destination centers, as well as improve patient outcome and satisfaction. Like other regional medical centers, robotics continues to change and improve the quality of complex surgical care available to our patient population. Over the last decade, the volume of complex laparoscopic operations has increased while maintaining excellent clinical outcomes. Given this change in the landscape of our practice, in the following study, we aimed to assess outcomes following MIE in a community cancer center. Our hypothesis is that robotic utilization affords the ability to provide high quality clinical care for complex surgical procedures, with outcomes equal to those at tertiary centers.

Methods

Results

Over the study time course 21 patients were identified that underwent MIE. Of these, 16 (76.2%) were male, and 5 (23.8%) were female. The mean age was 65 (49-85 years), and mean BMI was 23.2 (16.6-29.1). Our patients medical comorbidities included 15 (71.4%) patients with hypertension, 14 (66/7%) with GERD, 9 (42.9%) with hyperlipidemia, 6 (28.6%) who were overweight, 4 (19.1%) with coronary artery disease, 4 (19.1%) former smokers, 3 (14.3%) current smokers, 3 (14.3%) with history of deep vein thrombosis, 2 (9.5%) with history of pulmonary embolism, 2 (9.5%) with history of cerebrovascular accident, 2 (9.5%) with diabetes, 1 (4.8%) with history of coronary artery bypass graft, 1 (4.8%) with history of atrial fibrillation, and 1 (4.8%) with history of aortic aneurysm repair. Indications for surgical management included malignancy in 19 (90.48%), with 17 (80.95%) being adenocarcinoma, 1 (4.76%) squamous cell, and 1 (4.76%) malignant neuroendocrine tumor. All cancer patients (n = 19) received neoadjuvant therapy. Aside from malignancy, 1 (4.76%) individual underwent MIE for Barrett’s esophagus and 1 (4.76%) patient for achalasia.

Overall mean operative time was 381 minutes (253-678), and mean operative time significantly decreased after the first 10 cases from 502 minutes to 408 minutes (P = .0127). Mean non-operative time was 71 minutes, with average non-operative time similarly decreasing after the first 10 cases from 79 minutes to 66 minutes which was not significant (P = .0993). Mean estimated blood loss was 89 mL and decreased after first 10 cases from 155 mL to 32 mL and this was not significant (P = .2369). All patients underwent completely robotic abdominal and thoracic portions with no conversions to an open operation.

Hospital length of stay was 10.1 days (range = 6-26 d). This trended down after the first 10 cases from 11.2 down to 9.2 days without significance (P = .1864). Five patients (23.1%) were readmitted within 30 days, with 3 readmissions for dehydration within the first 9 postoperative days. All readmitted patients were subsequently discharged within 72 hours of readmission. A fourth readmission was for acute respiratory failure secondary to pneumonia and subsequent pulmonary emboli. Finally, the last readmission identified was for narcotic-associated constipation with the patient being discharged in 48 hours after readmission.

Postoperative complications are summarized in Table 1. Ninety-day survival was 100%. Overall survival was 90.4% (19 patients), with two deaths being secondary to disease progression. In our series, there were no anastomotic leaks or conduit necrosis

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Table 1.

Patient Characteristics

Complication	n	%
30-day readmission	5	23.81
90-day survival	21	100.00
Overall survival	19	90.5
Anastomotic leak	0	.00
Conduit necrosis	0	.00
Stricture	0	.00
J tube site complication	4	19.05
Reintubation postoperatively	2	9.52
Chylothorax	1	4.76
Post op PE	1	4.76
Post op EGD	2	9.52
Metastasis/recurrence	5	23.81
Pneumonia	4	19.05
New onset arrhythmia	4	19.05
Dehydration	4	19.05

Oncologic tumor characteristics of the patients with adenocarcinoma are summarized in Table 2. All cases achieved an R0 resection. Mean lymph node harvest was 14 nodes (range = 4-23). Thirteen patients (61.9%) had pathologically involved lymph nodes.

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Table 2.

Oncologic Characteristics

Tumor Characteristic	n	%
pCR	1	5.88%
T1	4	23.53%
T2	1	5.88%
T3	11	64.71%
N0	6	35.29%
N1	6	35.29%
N2	4	23.53%
N3	1	5.88%
Pathologic stage	n	%
pCr	1	5.26%
IA	0	.00%
IB	2	10.53%
IIA	0	.00%
IIB	4	21.05%
IIIA	2	10.53%
IIIB	7	36.84%
IVA	1	5.26%
IVB	0	.00%

Discussion

Our series clearly demonstrates clinical outcomes on par with large destination cancer centers, as well as very few postoperative complications and no anastomotic leaks.

Luketich et al. ⁴ Published the first multicenter prospective trial on MIE in 2015. During this time period, many MIE series have been published.^5-8 Most of these series have come from large destination referral centers. These outstanding centers serve to benchmark surgical outcomes for our field. As noted above, many patients do not have the resources to travel to such centers, a clear disparity in the care of these patients. This disparity is most pronounced in our most impoverished states, which includes Louisiana. Additionally, Louisiana carries a disproportionate burden from cancer. For example, in 2019 Louisiana had the union’s 5^th highest death rate from cancer at 168 deaths per 100,000 people according to the Centers for Disease Control. ⁹ These data paint quite a bleak outlook for anyone diagnosed with cancer, much less one requiring a technically demanding invasive operation.

Our operative technique using a linear stapled esophagogastrostomy resembles that described by Cerfolio et al ⁹ with slight modifications to the thoracic dissection. Our outcomes are comparable to their early series. While our length of stay is longer, our data suggest a down trend over time. Most notably in our series of 21 patients we did not have an anastomotic leak, much less than the ∼3-11% rate seen in the literature.^1,4,6-9 Additionally, no deaths were observed in the first 90 days which is comparable to the ∼0-10% rate seen in the literature.^1,4,6-9 We did have higher rates of both new onset arrythmias and pneumonia than Cerfolio et al ⁹ and these are clearly areas that can be improved upon. These data suggest that high quality cancer care is feasible for MIE with results on par with destination centers can safely and effectively be provided at regional centers. Aside from the clinical benefits, this local care is associated with tremendous benefits for patients without compromising clinical outcome. These benefits persist into the post op period, as should any complication arise it can be addressed by the operative team without travel or admission to a local hospital and subsequent transfer to a destination center.

There are notable limitations to this series. These data are those of a single surgeon at a single center and therefore our generalizability is limited. Additionally, we have a small sample size. Furthermore, we report our results at the very beginning of our program during the steepest part of the learning curve. We are nonetheless encouraged as we have achieved excellent outcomes during the steep slope of the learning curve for both the surgeon and hospital staff.

Overall robotic-assisted laparoscopic MIE at regional community centers is safe, effective, and offers several additional benefits that high-volume destination cancer centers cannot offer. Further research should be done to corroborate the current findings and continue to improve cancer care for our patients. The adoption of robotic-assisted laparoscopic surgery has not only changed the face of clinical surgery, but it may secondarily improve access to the highest levels of clinical care for many patients much closer to home.