Indian Journal of Surgery

, Volume 80, Issue 1, pp 24–29 | Cite as

Robot-Assisted Mckeown Esophagectomy is Feasible After Neoadjuvant Chemoradiation. Our Initial Experience

  • Ashish Goel
  • Swati H. Shah
  • Veda Padma Priya Selvakumar
  • Shubha Garg
  • Kapil Kumar
Original Article


Neoadjuvant chemoradiation has become the standard of care for esophageal cancer, especially for middle third esophageal lesions and those with squamous histology. Although more and more thoracic surgeons and surgical oncologists have now shifted to video-assisted and robot-assisted thoracoscopic esophagectomy; there is still limited experience for the use of minimal-assisted approaches in patients undergoing surgery after neoadjuvant chemoradiation. Most surgeons have concerns of feasibility, safety, and oncological outcomes as well as issues related to difficult learning curve in adopting robotic esophagectomy in patients after chemoradiation. We present our initial experience of Robot-Assisted Mckeown Esophagectomy in 27 patients after neoadjuvant chemoradiation, from May 2013 to October 2014. All patients underwent neoadjuvant chemoradiation to a dose of 50.4 Gy/25Fr with concurrent weekly cisplatin, followed by reassessment with clinical examination and repeat FDG PET/CT 6 weeks after completion of chemoradiation. Patients with progressive disease underwent palliative chemotherapy while patients with either partial or significant response to chemoradiation underwent Robot-Assisted Mckeown Esophagectomy with esophageal replacement by gastric conduit and esophagogastric anastomosis in the left neck. Out of 27 patients, 92.5 % patients had stage cT3/T4 tumours and node-positive disease in 48.1 % on imaging. Most patients were middle thoracic esophageal cancers (23/27), with squamous histology in all except for one. All patients received neoadjuvant chemoradiation and subsequently underwent Robot Assisted Mckeown Esophagectomy. The average time for robot docking, thoracic mobilization and total surgical procedure was 13.2, 108.4 and 342.7 min, respectively. The procedure was well tolerated by all patients with only one case of peri-operative mortality. Average ICU stay was 6.35 days (range 3–9 days). R0 resection rate of 96.3 % and average lymph node yield of 18 could be achieved. Pathological node negativity rate (pN0) and complete response (pCR) were 66.6 and 44.4 %, respectively. In the initial cases, four patients had to be converted to open due technical reasons or intraoperative complications. The present study, with shorter operative times, similar ICU stay, overall low morbidity, and mortality and optimal oncological outcomes suggest that robot-assisted thoracic mobilization of esophagus in patients with prior chemoradiation is feasible and safe with acceptable oncological outcomes. It has a shorter learning curve and hence allows for a transthoracic minimally invasive transthoracic esophagectomy to more and more patients, otherwise unfit for conventional approach.


RAME = robot assisted Mckeown esophagectomy CTRT = concurrent chemoradiation pCR = pathological complete response MIE = Minimally invasive esophagectomy 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no competing interests.


  1. 1.
    Hulscher JBF, van Sandwick JW, de Boer AG, et al. (2002) Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 347:1662–1669CrossRefPubMedGoogle Scholar
  2. 2.
    Biere SS, van Berge Henegouwen MI, Kirsten WM, et al. (2012) Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet 379:1887–1892CrossRefPubMedGoogle Scholar
  3. 3.
    Dimick JB, Goodney PP, Orringer MB, et al. (2005) Specialty training and mortality after esophageal cancer resection. Ann Thorac Surg 80:282–286CrossRefPubMedGoogle Scholar
  4. 4.
    Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al. (2003) Minimally invasive esophagectomy: outcomes in 222 patients. Ann Surg 238:486–494PubMedPubMedCentralGoogle Scholar
  5. 5.
    Nagpal K, Ahmed K, Vats A, et al. (2010) Is minimally invasive surgery beneficial in the management of esophageal cancer? A meta-analysis. Surg Endosc 24:1621–1629CrossRefPubMedGoogle Scholar
  6. 6.
    Sgourakis G, Gockel I, Radtke A, et al. (2010) Minimally invasive versus open esophagectomy: meta-analysis of outcomes. Dig Dis Sci 55:3031–3040CrossRefPubMedGoogle Scholar
  7. 7.
    Biere SS, Cuesta MA, van der Peet DL, et al. (2009) Minimally invasive versus open esophagectomy for cancer: a systematic review and meta-analysis. Minerva Chir 64:121–133PubMedGoogle Scholar
  8. 8.
    Verhage RJ, Hazebroek EJ, Boone J, et al. (2009) Minimally invasive surgery compared to open procedures in esophagectomy for cancer: a systematic review of the literature. Minerva Chir 64:135–146PubMedGoogle Scholar
  9. 9.
    Weksler B, Sharma P, Moudgill N (2012) Robot-assisted minimally invasive esophagectomy is equivalent to thoracoscopic minimally invasive esophagectomy. Dis Esophagus 25:403–409CrossRefPubMedGoogle Scholar
  10. 10.
    Gemmill EH, McCulloch P (2007) Systematic review of minimally invasive resection for gastro-oesophageal cancer. Br J Surg 94:1461–1467CrossRefPubMedGoogle Scholar
  11. 11.
    Ninomiya I, Okamoto K, Fujimura T, Fushida S, Osugi H, Ohta T (2014) Oncologic outcomes of thoracoscopic esophagectomy with extended lymph node dissection: 10-year experience from a single center. World J Surg 38(1):120–130CrossRefPubMedGoogle Scholar
  12. 12.
    Mao T, Fang WT, Gu ZT, Yao F, Guo XF, Chen WH (2012) Comparative study of perioperative complications and lymphadenectomy between minimally invasive esophagectomy and open procedure. (Article in Chinese). Zhongua Wei Chang Wai KeZa Zhi 15(9):922–925Google Scholar
  13. 13.
    Tsujimoto H, Takahata R, Nomura S, et al. (2012) Video-assisted thoracoscopic surgery for esophageal cancer attenuates postoperative systemic responses and pulmonary complications. Surgery 151(5):667–673CrossRefPubMedGoogle Scholar
  14. 14.
    Ninomiya I, Osugi H, Fujimura T, et al. (2014) Thoracoscopic esophagectomy with extended lymph node dissection in the left lateral position: technical feasibility and oncologic outcomes. Dis Esophagus 27(2):159–167CrossRefPubMedGoogle Scholar
  15. 15.
    Guo W, Zou YB, Ma Z, et al. (2013) One surgeon’s learning curve for video-assisted thoracoscopic esophagectomy for esophageal cancer with the patient in lateral position: how many cases are needed to reach competence? Surg Endosc 27(4):1346–1352CrossRefPubMedGoogle Scholar
  16. 16.
    Xie X, Fu JH, Wanq JY, et al. (2012) Analysis of learning process of video-assisted minimally invasive esophagectomy for thoracic esophageal carcinoma. (Article in Chinese). Zhonghua Wei Chang Wai KeZa Zhi 15(9):918–921Google Scholar
  17. 17.
    Sjoquist KM, Burmeister BH, Smithers BM, et al. (2011) Survival after neoadjuvant chemotherapy or chemoradiotherapy for resectable esophageal carcinoma: an updated meta-analysis. Lancet Oncol 12(7):681–692CrossRefPubMedGoogle Scholar
  18. 18.
    Van Hagen P, Hulshof MCCM, van Lanschot JJB, et al. (2012) Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med 366:2074–2084CrossRefPubMedGoogle Scholar
  19. 19.
    Warner S, Chang YH, Paripati H, et al. (2014) Outcomes of minimally invasive esophagectomy in esophageal cancer after neoadjuvant chemoradiotherapy. Ann Thorac Surg 97(2):439–445CrossRefPubMedGoogle Scholar
  20. 20.
    David BK, Rossidis G, Zoltecki RA, et al. (2011) Minimally invasive esophagectomy is safe and effective following neoadjuvant chemoradiation therapy. Ann Surg Oncol 18(12):3324–3329CrossRefGoogle Scholar
  21. 21.
    Coker AM, Barajas Gamboa JS, Cheverie J, et al. (2014) Outcomes of robotic assisted transhiatal esophagectomy for esophageal cancer after neoadjuvant chemoradiation. J Laparoendosc Adv Surg Technol 24(2):89–94CrossRefGoogle Scholar
  22. 22.
    van Hillegersberg R, Boone J, Draaisma WA, et al. (2006) First experience with robot-assisted thoracoscopic esophagolymphadenectomy for esophageal cancer. Surg Endosc 20:1435–1439CrossRefPubMedGoogle Scholar
  23. 23.
    Kernstine KH, DeArmond DT, Shamoun DM, et al. (2007) The first series of completely robotic esophagectomies with three-field lymphadenectomy: initial experience. Surg Endosc 21:2285–2292CrossRefPubMedGoogle Scholar
  24. 24.
    Anderson C, Hellan M, Kernstine K, et al. (2007) Robotic surgery for gastrointestinal malignancies. Int J Med Robot 3:297–300CrossRefPubMedGoogle Scholar
  25. 25.
    Kim DJ, Hyung WJ, Lee CY, et al. (2010) Thoracoscopic esophagectomy for esophageal cancer: feasibility and safety of robotic assistance in the prone position. J Thorac Cardiovasc Surg 139:53–59CrossRefPubMedGoogle Scholar
  26. 26.
    Galvani CA, Gorodner MV, Moser F, et al. (2008) Robotically assisted laparoscopic transhiatal esophagectomy. Surg Endosc 22:188–195CrossRefPubMedGoogle Scholar
  27. 27.
    Bodner J, Wykypiel H, Wetscher G, et al. (2004) First experiences with the da Vinci operating robot in thoracic surgery. Eur J Cardiothorac Surg 25:844–851CrossRefPubMedGoogle Scholar
  28. 28.
    Bodner JC, Zitt M, Ott H, et al. (2005) Robotic-assisted thoracoscopic surgery (RATS) for benign and malignant esophageal tumors. Ann Thorac Surg 80:1202–1206CrossRefPubMedGoogle Scholar

Copyright information

© Association of Surgeons of India 2016

Authors and Affiliations

  1. 1.BLK Super Speciality HospitalNew DelhiIndia
  2. 2.Rajiv Gandhi Cancer Institute and Research CentreNew DelhiIndia

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