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Page 6 of 11 Bongiolatti et al. Mini-invasive Surg 2020;4:41 I http://dx.doi.org/10.20517/2574-1225.2020.28

Table 3. Post-operative outcomes of RAMIE
Post-operative Complications
Author
mortality 90day Overall Respiratory Anastomotic Cardiac VCP
Boone et al. [18] 3 (4.05%) NA 21 (44.7%) 10 (21.3%) 6 (12.7%) 9 (19.1%)
Puntambekar et al. [27] NA NA 2 (6.25%) 3 (9%) NA NA
Dunn et al. [19] 1( 2.5%) NA 26 (65%) 10 (25%) NA 14 (35%)
Sarkaria et al. [21] 1 (5%) 5 (24%) NA 3 (14%) NA 3 (14%)
Suda et al. [32] 0 8 (50%) 1 (6.25%) 6 (37.5%) 1 (6.25%) 6 (37.5%)
de la Fuente et al. [36] NA 14 (28%) 5 (10%) 2 (4%) 5 (10%) NA
Yerokun et al. [39] NA NA NA NA NA NA
Weksler et al. [17] 7.8% NA NA NA NA NA
van der Sluis et al. [14] 5 (9%) 32 (59%) 17( 32%) 13 (24%) 17 (32%) 5 (9.1%)
Harbison et al. [16] 3 (3%) 31 (31%) 11 (11%) 14 (14%) NA NA
Yang et al. [22] 0 122 (45%) 71 (25.3%) 32 (11.8%) 9 (3.3%) 79 (29%)
Tagkalos et al. [28] (5%) NA (12%) (12%) NA NA
Sarkaria et al. [31] 1 (1.56%) 39 (60.9%) NA 2 (3.1%) 5 (7.8%) 2 (3.1%)
Yun et al. [29] 0 49 (37.7%) NA 4 (3.1%) 1 (0.8%) 33 (25.4%)

VCP: vocal cord palsy; NA: not available

showed similar mortality between RAMIE and MIE (3% vs. 2.24%); other large retrospective studies have
demonstrated that RAMIE had similar mortality rates when compared with MIE and OE .
[22]
Post-operative complications were reported in eight studies and ranged between 24% and
60.9% [14,16,21,22,29,31,32] . Although it can now be performed through a minimally invasive approach,
esophagectomy is still associated with a high incidence of overall complications. In the RCT, the overall
[16]
[14]
complication rate was assessed at 59% ; Harbison et al. reported an overall morbidity rate of 31%, while
[29]
[22]
other large single-institution studies reported variable rates from 45% to 37.7% .
The absence of thoracotomy did not avoid respiratory complications, which were reported in 6.25% to
65% of cases [14,16,18,22,27,39] . Some possible mechanisms could be involved: prolonged one-lung ventilation,
reduced cough reflex due to vagus nerve injury, alteration of swallowing and consequent aspiration, and
the presence of comorbidities such as advanced age and chronic obstructive pulmonary disease [14,16,18,22,27,39] .
Cardiac arrhythmias were frequent and reported in 0.8% to 32% of cases [18,22,29] .

Anastomotic complications are still the Achilles’ heel of MIE and RAMIE. No subtype (mechanical
vs. hand-sewn, end-to-end vs. end-to-side) nor location (cervical or intrathoracic) of esophagogastric
anastomosis have shown to be more reliable and safer than others and even after RAMIE, the anastomotic
complication rate is still significant and ranges between 3.1% and 37.5%. Although data about anastomotic
leak rates are available in most studies, anastomotic stricture is less frequently reported even if it has a
[14]
negative impact on the quality of life. The RCT described the need of anastomotic dilatation in 52% of
patients who underwent RAMIE, while other single institutional reports showed lower rates of stricture or
[21]
anastomotic dilatation (4.7%) and the majority of these patients underwent intrathoracic anastomosis .

Although the robot-assisted platform has a magnified three-dimensional view, recurrent laryngeal nerve
palsy was described in eight papers and it was frequently reported after cervical anastomosis (9.1%-35%),
probably due to extensive lymph node dissection. Chylothorax is another frequent complication and
assessed from 0% to 17% [14,21,22,29] ; in the RCT, 4% of patients needed re-intervention for chylothorax .
[14]
Some centers perform a prophylactic thoracic duct ligation just above the diaphragm between the
descending aorta and esophagus [14,27] .

Only two studies have focused their attention on quality of life after RAMIE, reporting controversial
[31]
results: Sarkaria et al. evaluated the quality of life using the Functional Assessment of Cancer Therapy-