The report is a product of the VA/HSR Evidence Synthesis Program.

Systematic Review: Robot-Assisted Surgery for Esophageal Cancer: Analysis of Short- and Long-term Outcomes

Esophageal cancer is the seventh most common cancer diagnosis globally each year, with an estimated 572,000 new cases in 2018. Esophagectomy is an important component of esophageal cancer treatment and is performed using open, conventional minimally invasive techniques (thoracoscopic and laparoscopic), or robot-assisted approaches. Historically, open esophagectomy (OE) is the standard surgical approach for esophageal cancer; however, OE is a technically difficult operation with an associated morbidity and mortality of nearly 50% and 5%, respectively. While minimally invasive approaches also are technically challenging, trials exploring laparoscopic and thoracoscopic techniques have demonstrated fewer post-operative complications and similar oncologic outcomes. Robot-assisted surgery for esophageal cancer is being increasingly used, with more than 1,800 robotic esophagectomies performed worldwide in 2016, a 9-fold increase from those performed in 2009. Despite the rapid adoption of robot-assisted minimally invasive esophagectomy (RAMIE), several questions remain about its utility compared to OE and other minimally invasive approaches, such as video-assisted minimally invasive esophagectomy (VAMIE), especially concerning long-term oncologic outcomes. Another important consideration is the economics of the robotic platform, which require an upfront investment and costs for annual maintenance, instruments, staff and training, and infrastructure upgrade.

This systematic review sought to examine how RAMIE compares to open and other minimally invasive approaches, with an emphasis on long-term oncologic outcomes. Investigators with VA’s Evidence Synthesis Program (ESP) Center in West Los Angeles, CA searched the literature, including PubMed and Ovid Medline (1/1/13-5/5/20), Cochrane (1/1/13-5/11/20), and Embase (1/1/13-5/6/20). After reviewing 390 citations, the investigators used 20 publications with clinical outcomes, 1 publication with clinical and cost outcomes, and 1 publication with only cost outcomes for their analysis.

Summary of Findings

Esophagectomy is a complex procedure with a high rate of morbidity, and while the robot-assisted approach has the potential to improve several important patient outcomes, current data are too limited to provide definitive conclusions. Specific findings include:

• RAMIE is associated with longer OR times compared with VAMIE (low certainty of evidence) and open esophagectomy (high certainty of evidence) based on consistency.
• There was greater lymph node harvest with RAMIE compared with VAMIE (low certainty of evidence) and open esophagectomy (moderate certainty of evidence).
• There were no differences with length of stay (LOS) in a hospital or total complications between RAMIE and VAMIE (moderate certainty of evidence). There was very low certainty of evidence that RAMIE was associated with a shorter LOS compared with open esophagectomy, due to limited data.
• There were no differences in short-term mortality (within 90 days) for RAMIE compared with VAMIE (moderate certainty of evidence) or open esophagectomy (low certainty of evidence).
• Regarding long-term outcomes, there was very low certainty of evidence that cancer recurrence is no different between RAMIE and VAMIE or open esophagectomy due to a lack of research on this outcome.
• Formal cost-effectiveness studies comparing RAMIE with other approaches were not identified.

There were no studies specific to VA populations. However, benefits for the robot-assisted approach may still be realized despite patient-level differences (VA patients have more comorbidities than the general population), which will need to be confirmed in future studies.

Research Gaps/Future Research

Future research should include randomized controlled trials (RCTs) or well-designed prospective matched studies with adequate power and follow-up to assess long-term as well as oncologic outcomes in patients undergoing robot-assisted surgery for esophageal cancer, including the determination of risks and long-term oncologic outcomes. The surgeon’s physical experience using robot-assisted techniques also is important to assess. The robotic platform has demonstrated improved ergonomics and less musculoskeletal complaints from surgeons compared to open and other minimally invasive surgical techniques, but this has not been universally observed. Research is needed to assess quality of life, chronic physical injuries, and longevity across approaches.

Further, there has been evidence in other cancer types (e.g., gynecologic oncology) that worse survival may occur with minimally invasive surgery. This finding supports the ongoing need for rigorous investigation into the comparative benefits and risks of robotic surgery across specialties and cancer types.

Mederos MA, de Virgilio MJ, Girgis MD, Toste P, Childers CP, Ye L, Shenoy R, Mak SS, Begashaw M, Booth MS, Maggard-Gibbons M, Shekelle PG, Robot-Assisted Surgery for Esophageal Cancer: Analysis of Short and Long-Term Outcomes. Los Angeles: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #05-226; 2020.

To view the full report, go to vaww.hsrd.research.va.gov/publications/esp/robot-assisted-esophagectomy.cfm (Intranet only)

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

See all reports online.