Authors reply to “Robotic esophagectomy: a better way or just another way?”.
Thank you to the reviewer for the constructive comments on our manuscript of a case report of robotic-assisted three-field esophagectomy (1). The comments briefly reviewed the current state of minimal invasive esophagectomy (MIE) and asked the pragmatic question “Is robotic esophagectomy a better way or just another way?”.
Esophageal cancer ranks fifth in morbidity and fourth in mortality among all of the cancers in China. Patients often suffer great trauma and low quality of life after complex yet effective esophagectomies, and surgeons do their best to reduce the trauma of surgery, although early studies suggested that MIE did not provide advantages over open surgery with regards to postoperative recovery and complications (2), recent studies have demonstrated the benefits of MIE. In 2013, Dolan et al. (3) published a comparative study of 146 cases of open esophagectomy and MIE, and they showed that the MIE group had less blood loss, a higher amount of lymph node harvested, and shorter hospital stays than the open esophagectomy group, with no difference in the 5-year survival between the groups. In 2016, Guo et al. (4) performed a meta-analysis of 1,549 cases and found that MIE led to fewer postoperative complications and a similar survival rate when compared to open surgery. Furthermore, for patients with middle and lower esophageal cancers, a totally minimally invasive Ivor-Lewis esophagectomy can lead to less trauma, reduced postoperative pain, and fewer lung complications than open surgery (5). The benefits of MIE were also confirmed in a randomized controlled trial, which found that the short-term oncologic results of MIE were comparable with standard open surgery (6). Although it has been clearly shown that MIE associates with faster recovery and less morbidity, the long-term outcomes and oncologic results remain in dispute.
In addition, the reviewer mentioned that fewer esophagectomies were performed in the U.S. because of the level of surgical volume. In China, because esophageal cancer is a common disease, Chinese surgeons will have the opportunities to develop the skills that are required to perform robotic-assisted esophagectomies. As in the U.S., there has been an increase in robotic thoracic surgeries in China. Since 2015, we have performed over 70 robotic-assisted esophagectomies, and preliminary results showed that the short-term outcomes, including 1-year overall survival and disease-free survival, were similar for robotic and open surgeries. In addition, our department performed a clinical trial entitled “Robot-assisted Ivor-Lewis esophagectomy: short-term outcomes of a single-arm phase II trial” to verify the outcomes of the robotic esophagectomies. Recently, we have attempted manual intrathoracic anastomosis for several cases, and flexible robot arms allowed for the most difficult step of MIE to be performed smoothly.
However, currently there is a lack of definitive evidence to support the superiority of robotic esophagectomy with regards to morbidity and mortality (7), and the cost associated with robotic esophagectomy is high. While it appears that robotic esophagectomy is a safe and reliable method nowadays, we believe that with the development of instruments and with the development of training programs to learn the technique, the advantages of robotic surgery will be amplified in the future, and the robotic esophagectomy will be a better option.
We would like to acknowledge David Tian, Senior Editor of AME Publishing Company, for editing support.
Funding: This study was supported by the grant from Science and Technology Commission of Shanghai Municipality Medical Guidance Science & Technology Support Project (16411966100), Shanghai Municipal Education Commission-Gaofeng Clinical Medicine Grant Support (20172005) and Shanghai Municipal Commission of Health and Family Planning Outstanding Academic Leaders Training Program (2017BR055).
Conflicts of Interest: The authors have no conflicts of interest to declare.
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