Can robot-assisted oesophagectomy really improve outcomes?

Chao and his team present a multicenter, open label, randomized clinical superiority trial, on robot-assisted oesophagectomy (RAO) as compared to video-assisted oesophagectomy (VAO) (REVATE trial), performed in three high-volume centers in Asia (1). In an era of exponential growth of robotic surgery, medical literature still lacks more high-quality studies in the field. This paper from Chao et al. is an interesting prospective randomized trial comparing outcomes of two complex procedures applying robot or video assistance, realized by experts and deserves to be highlighted to the scientific community, mainly due to the absence of surgical quality papers in the subject.

Every surgeon knows how hard it is to recruit, operate and follow patients prospectively which increases the importance of this paper. Furthermore, at a time when robotic surgery appears to become a surgical specialty, it is essential that groups specialize in a disease, organ or system such as esophageal cancer, carry out elegant studies like these. This Asian group is experienced in minimal invasive esophageal cancer treatment (2,3) and Asia is a continent with high incidence of squamous cell esophageal carcinoma which gives extra confidence to the findings. The learning curve for robotic surgery, however, remains questionable and it seems that the more complex the procedure, the greater the number of procedures that must be performed to complete the learning curve (4). Fifty previously RAO, defined as inclusion criteria by the authors, should be insufficient to consider the surgeon as specialist in a complex procedure such as robot assisted oesophagectomy (5).

The main premise of this study is the adequacy and safety of lymph node dissection along the recurrent laryngeal nerve (RLN) and the risk of injury of this nerve, that may lead to vocal cord palsy, which culminates in an increase in the risk of pulmonary complications. They could demonstrate that RAO was associated with a higher success rate in lymph node dissection (88% vs. 69%, P<0.001) along the left RLN and a tendency of lower incidence of permanent nerve palsy compared with VAO, although it was considered that resection of only one lymph node was sufficient for success statement. It is important to notice that there are other trials demonstrating a median rate of RLN lymph node dissection of 6 [0–15] with robot-assistance (6). The complex organized lymphatic system surrounding the esophagus, and the multidirectional connections of the system make uncertain the effect on disease recurrence and overall survival related to extensive lymphadenectomy (7,8). Another important point is related to the fact that the nerve injury may have occurred during the cervical dissection and may not be exclusively related to the technology used, robotic or video. Even so, interestingly, the greater number of RLN injuries was not correlated with increased bronchoaspiration or postoperative pneumonia, which should be one of the main concerns when having this injury (9).

Secondary endpoints of this study such as postoperative complication rates, blood loss, hospital stay, and mortality had no statistical difference between the groups. In addition, in the Western countries the prevalence of squamous cell esophageal carcinoma is much lower than Asia, and population characteristics as obesity may weaken the external validation of the findings (10). Furthermore, new technologies like robotics are capable of promoting excessive enthusiasm and bring up publications with a tendency of positive results (11,12).

Finally, Chao et al., with a very expert point of view, could find a tendency of more precise lymph node dissection with robotic assistance, although the clinical significance of these findings is completely uncertain, and these limitations are well described by the authors. In conclusion, RAO was not inferior to VAO, a result that is commonly reported in studies involving robotic assistance. Therefore, the real value of lymph nodes dissection through the RLN to improve overall survival and recurrence, even as robotic surgery for the treatment of esophageal cancer remains with the need for further work to shed light on this very relevant topic given the exponential growth in the number of robotic surgeries that are still costly for health services (13).

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Clinical Trials Review. The article has undergone external peer review.

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