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Page 8 of 11 Matto et al. Mini-invasive Surg. 2025;9:19 https://dx.doi.org/10.20517/2574-1225.2025.51

Finally, an endoscope is passed to check for anastomotic leaks and to ensure the gastric conduit lies without
shelf formation or redundancy. If a shelf is detected, we attempt to carefully push the conduit further into
the abdominal cavity. Should these efforts fail and a significant abnormal shelf is identified near the
thoracoabdominal junction, we consider performing laparoscopy at the conclusion of the thoracic
procedure. The patient is repositioned supine, and a laparoscope is introduced. This can be done
laparoscopically, though the robotic system may be redocked if needed. If re-entry into the abdomen is
required, we further reduce and straighten the redundant gastric conduit and secure it in place from below.
This step is rarely necessary when careful attention is paid to conduit measurement and delivery during the
initial anastomosis construction.

Postoperative protocols
While this is primarily a technique paper, we would like to share some unpublished details regarding our
general postoperative management of RAMIE patients. Ideally, patients are extubated in the operating room
immediately following surgery. If the anesthesia team determines that the patient is not ready, extubation is
delayed until postoperative day (POD) 1. A NGT is placed at the end of the procedure and typically
removed on POD1. After NGT removal, patients may have minimal ice chips (approximately 1 teaspoon)
every 2-3 h, assuming they pass a bedside swallow evaluation. On POD3, a barium swallow study is
conducted. If concerns arise during the bedside evaluation, a modified barium swallow may be performed
to test for aspiration. The patient remains NPO until they demonstrate safe swallowing without coughing or
signs of aspiration. If the patient passes the barium swallow without evidence of a leak, they may begin with
1-2 oz of clear liquids and advance rapidly over the following days to a soft diet (approximately 3-4 oz every
4 h). During this transitional period, the primary source of nutrition is via jejunostomy tube feeds.

Regarding ambulation, the patient is assisted out of bed to a chair on the morning of POD1. If overall
progress is satisfactory, the patient is transferred to a monitored unit and begins assisted ambulation,
potentially as early as POD1. Adjustments to ambulation are made based on the patient’s clinical status.

RESULTS
In a previously published, propensity-matched comparison of MIE and RAMIE, we reported on 181 MIE
patients and 65 RAMIE patients treated between 2014 and 2021 . The primary endpoints of this
[5]
retrospective study were overall survival and disease-free survival. Kaplan-Meier curves demonstrated
comparable outcomes between MIE and RAMIE, with P-values of 0.69 and 0.70, respectively.

A total of 83 patients underwent RAMIE during the study period, of whom 65 were included in the detailed
propensity-matched analysis. These cases were relatively evenly distributed across the study period, with a
slight increase in the last 3 years compared to the first 4 years. Initially, only one surgeon performed
RAMIE; over time, three additional surgeons were credentialed and began performing the procedure. The
[5]
inclusion and exclusion criteria for the cohort and matched subset were previously described . In brief,
inclusion criteria encompassed all patients who underwent MIE or RAMIE. Exclusion criteria included
patients over 87 years of age, those with metastatic disease or cirrhosis, and patients who underwent bipolar
exclusion or hybrid procedures. Table 1 summarizes patient demographics. The median age was 67 years,
and the majority were male (81.5%). Most patients presented with clinical stage III disease (67.7%) and had
adenocarcinoma (86.2%). Perioperative outcomes for RAMIE are presented in Table 2. The median number
of lymph nodes removed was 32, significantly higher than the 29 removed in MIE cases (P-value = 0.02). An
R0 resection was achieved in 64 patients (98.5%). The median operative time for RAMIE was 614 min,
which did not significantly differ from that of MIE (625 min; P-value = 0.86). The 90-day mortality rate was
3.1% (2 patients) for RAMIE and 2.4% (4 patients) for MIE (P-value = 0.73). Major morbidities associated
with RAMIE are listed in Table 3. Compared with MIE, there were no statistically significant differences in