Robot geassisteerde slokdarm chirurgie. Dr. P.C. van der Sluis MD, PhD, Msc. AIOS Heelkunde jaar 6

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1 Robot geassisteerde slokdarm chirurgie Dr. P.C. van der Sluis MD, PhD, Msc. AIOS Heelkunde jaar 6 P.C.vandersluis-2@umcutrecht.nl

2 Slokdarmkanker Jaarlijks: +/ nieuwe diagnoses Incidentie: 6% toename per jaar Neoadjuvante (radio)chemotherapie Oesofagectomie (Open) En bloc lymfeklieren

3 Chemoradiotherapie (5x) Carboplatin Paclitaxel

5 Terug naar spreekuur chirurg: Extra beeldvorming (metastasen) Conditie Ongeveer 6 weken na chemoradiotherapie operatie Geen postoperatieve chemo(radio)therapie

10 Pulmonale complicaties Cardiale complicaties Hoge mortaliteit Pijn postoperatief

11 Patienten met slechte hart of long functie Geen verdachte klieren hoog in het mediastinum

17 Pulmonale complicaties Cardiale complicaties Mortaliteit Pijn postoperatief Is het mogelijk om de morbiditeit van deze ingreep te verlagen?

18 Minder bloedverlies Minder complicaties Minder pijn Sneller herstel Betere cosmetiek Vrijwel geen littekenbreuken

19 Surgical Approach 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Open Minimally invasive P<0.001 Haverkamp et al. Dis Esoph 2016

20 Minimally invasive esophagectomy (MIE) 1 Randomized controlled trial MIE vs open (TIME-trial) Fewer pulmonary complications: 7(12%) vs 19 (34%) Better QoL (also after 1 year) However: not widely adapted Biere et al Lancet 2012

21 Minimally invasive surgery Leap forward for patients Step back for surgeons 2 dimensional vision Disturbed eye-hand coordination Loss of dexterity Assistant for camera view

22 3-dimensional view Robot-assisted scopic surgery Natural eye-hand axis High degree of freedom Complex scopic procedures

23 Conclusion RAMIE MIE Reduced morbidity Comparable oncologic results RAMIE alternative to MIE Equal benefits Technical advantages Van der Sluis et al. Ann Surg Oncol 2015

24 Robot-assisted minimally invasive thoracoscopic esophagectomy (RAMIE, 2003)

26 Set-up OR RAMIE

27 Filmpje

28 Lancet 2009

30 Stage 1: Idea 21 patients Description of technique First experience Proof of concept

31 Stage 2a: Development 47 patients Technical feasibility and safety Early technical modifications

32 Stage 2b: Exploration 108 patients Oncologic long term follow up and safety

33 Survival RAMIE n=312 77% T3 and T4 tumors 70% N+ 70% neoadjuvant ther Median FU: 57 mths Van der Sluis et al. Ann Surg Oncol 2015

34 Analysing the learning curve of RAMIE October 2003 August 2016 Total RAMIE cases 312 Proctor 232 Novice 80

35 Learning curve RAMIE(cusum analysis) Operating times, blood loss: Procter completed : 70 procedures, 5 years Novice Completed : 24 procedures, 1 year Reduction of the learning curve compared to proctor: 66% in number of operations 76% in time

36 Stage 1-2b: completed Feasible Technically safe Oncologically safe Completed learning curve

37 Stage 3: Exploration Van der Sluis et al. Trials 2012

38 b ROBOT trial open vs RAMIE RCT ROBOT trial: Robot assisted versus open transthoracic esophagectomy Postoperative complications (primary end point) Intraoperative details Pain scores Quality of life Oncological outcomes Van der Sluis et al. Trials 2012

39 Inclusion percentage 112 / 138 (81%) Van der Sluis et al. submitted 2017

41 Results ROBOT Trial Postoperative complications RAMIE 59% RR 0.74 ( ; P=0.02) OPEN 80% Median blood loss RAMIE 400ml (P<0.001) OPEN 568ml

42 Results ROBOT Trial Pulmonary complications RAMIE 32% (RR 0.54 ( ; P=0.005) OPEN 58% Cardiac Complications RAMIE 22% (RR 0.47 ( ; P=0.006) OPEN 47%

43 Results ROBOT Trial Functional recovery at day 14 RAMIE 70% (RR 1.48 ( ; P=0.038) OPEN 51% Functional recovery at day 14 RAMIE 70% (RR 1.48 ( ; P=0.038) OPEN 51%

44 Quality of life Quality of life (QLQ-C30) RAMIE (n=54) OTE (n=55) P-value Health-related (discharge) Health-related (6 weeks) Physical functioning (discharge) Physical functioning (6 weeks) 57.9 ( ) 44.6 ( ) ( ) 57.6 ( ) ( ) 41.0 ( ) ( ) 58.6 ( ) Van der Sluis et al. submitted 2017

45 Postoperative pain (VAS) Van der Sluis et al. submitted 2017

46 RAMIE n=54 (%) OTE n=55 (%) P-value Radicality of Surgery 0.35 R0 R1 Irresectable disease 50 (93) 2 (4) 2 (4) 53 (96) 2 (4) 0 (0) Lymph nodes number (number IQ range) 27 (17-33) 25 (17 31) 0.41 Type of carcinoma 41 (76) 43 (78) 0.78 Adenocarcinoma 13 (24) 12 (22) Squamous cell carcinoma Pathological stadium 0.62

47 Survival at medium follow up of 38 months ROBOT Open Van der Sluis et al. submitted 2017

48 Conclusions ROBOT Trial randomized controlled trial RAMIE vs OPEN improves postoperative outcome Lower percentage of postoperative complications Lower percentage cardio-pulmonary complications Less postoperative pain Better quality of life Better short term functional recovery Oncologically comparable Van der Sluis et al. submitted 2017

49 Stage 4: Long term study Extension of indications (ct4b) Salvage surgery Training of other centers Training residents ERAS (EROES)

50 Stage 4: Vergelijking met MIE (thoracolaparoscopic)

51 Stage 4: Vergelijking met MIE (thoracolaparoscopic)

52 Stage 4: Vergelijking met MIE (thoracolaparoscopic)

53 Stage 4: Vergelijking met MIE (thoracolaparoscopic)

54 Stage 4: Vergelijking met MIE (thoracolaparoscopic)

55 UMC Utrecht: future directions Liver Pancreas Rectum Thyroid (Mamma) (colon) In 10 years: all gastrointestinal surgery

56 UMC Utrecht: future directions Liver Pancreas Rectum Thyroid (Mamma) (colon) In 10 years: all gastrointestinal surgery

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