Learning curve of Robotic Assisted Minimally Invasive Ivor Lewis Esophagectomy (RAMIE): initial experience

The aim of the study was to investigate the learning curve and perioperative outcomes of implementing Robotic Assisted Minimally Invasive Ivor Lewis Esophagectomy (RAMIE) at a tertiary referral center.

Retrospective review of patients  ≥ 18 years old between June 2019 and June 2024 of 70 consecutive patients who underwent RAMIE. The primary outcome was operative time. Secondary outcomes included estimated blood loss (EBL), conversion rate, lymph node yield, positive proximal margin and in-hospital mortality. Cumulative sum (CUSUM) analyses were performed to identify proficiency for operating time and intraoperative blood loss. A multivariable general linear model (GLM) was utilized to measure the strength and direction of the associations that exist between the predictor variables, Age, Sex, Race, BMI, Neoadjuvant treatment, Tumor stage, Cancer type, Clavien-Dindo and EBL, with the outcome variable, operative time. A Kaplan-Mayer survival curve was calculated over the duration of the study. A t-test was calculated to compare survival based on whether cancer was present or not.

70 RAMIE procedures were performed during the study period. The operative time analysis showed technical proficiency was acquired at 55 cases. No significant change in intraoperative blood loss was indicated. The multivariable modeling approach showed Sex was significantly associated with operative time (F = 226.62, p < .001). The Kaplan-Meier survival curve showed overall survival was statistically significant when compared by cancer stage (Mantel-Cox Log Rank χ² = 7.13, p = 0.008). Survival since the day of surgery was statistically significantly less for those patients with evidence of cancer (t = 2.87, p = 0.006).

RAMIE appears to have a short learning curve. Prospective studies examining the learning curve and outcomes of robotic esophagectomies compared to the outcomes of non-robotic cases is suggested.