Comparison of Clinical Outcomes of Robot-Assisted, Video-Assisted, and Open Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-analysis

IMPORTANCE: The utilization of robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer is increasing, despite limited data comparing RAMIE with other surgical approaches. OBJECTIVE: To evaluate the literature for clinical outcomes of RAMIE compared with video-assisted minimally invasive esophagectomy (VAMIE) and open esophagectomy (OE). DATA SOURCES: A systematic search of PubMed, Cochrane, Ovid Medline, and Embase databases from January 1, 2013, to May 6, 2020, was performed. STUDY SELECTION: Studies that compared RAMIE with VAMIE and/or OE for cancer were included. DATA EXTRACTION AND SYNTHESIS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline, data were extracted by independent reviewers. A random-effects meta-analysis of 9 propensity-matched studies was performed for the RAMIE vs VAMIE comparison only. A narrative synthesis of RAMIE vs VAMIE and OE was performed. MAIN OUTCOMES AND MEASURES: The outcomes of interest were intraoperative outcomes (ie, estimated blood loss [EBL], operative time, lymph node [LN] harvest), short-term outcomes (anastomotic leak, recurrent laryngeal nerve [RLN] palsy, pulmonary and total complications, and 90-day mortality), and long-term oncologic outcomes. RESULTS: Overall, 21 studies (2 randomized clinical trials, 11 propensity-matched studies, and 8 unmatched studies) with 9355 patients were included. A meta-analysis was performed with 9 propensity-matched studies comparing RAMIE with VAMIE. The random-effects pooled estimate found an adjusted risk difference (RD) of −0.06 (95% CI, −0.11 to −0.01) favoring fewer pulmonary complications with RAMIE. There was no evidence of differences between RAMIE and VAMIE in LN harvest (mean difference [MD], −1.1 LN; 95% CI, −2.45 to 0.25 LNs), anastomotic leak (RD, 0.0; 95% CI, −0.03 to 0.03), EBL (MD, −6.25 mL; 95% CI, −18.26 to 5.77 mL), RLN palsy (RD, 0.01; 95% CI, −0.08 to 0.10), total complications (RD, 0.05; 95% CI, −0.01 to 0.11), or 90-day mortality (RD, −0.01; 95% CI, −0.02 to 0.0). There was low certainty of evidence that RAMIE was associated with a longer disease-free survival compared with VAMIE. For OE comparisons (data not pooled), RAMIE was associated with a longer operative time, decreased EBL, and less pulmonary and total complications. CONCLUSIONS AND RELEVANCE: In this study, RAMIE had similar outcomes as VAMIE but was associated with fewer pulmonary complications compared with VAMIE and OE. Studies on long-term functional and cancer outcomes are needed.