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Triantafyllou et al. Mini-invasive Surg 2023;7:31 https://dx.doi.org/10.20517/2574-1225.2023.48 Page 5 of 8

CURRENT AND FUTURE TRENDS
The technologic advances of RAMIE are particularly useful in overcoming the practical challenges in
performing an intrathoracic anastomosis. Even when three-dimensional technology is available in MIE, the
enhanced view of the surgical field and the accurate perception of the depth through RAMIE are great assets
[6]
for the surgeon . Additionally, the articulated instruments and the degrees of freedom provided in RAMIE
can give the advantage of more convenient angles and manoeuvres, either when stapling or when selecting
the hand-sewn technique. The improved ergonomics in the limited space of the thoracic mobilisations,
firing of instruments, and suturing are of paramount importance.

The preliminary results of the RAMIE RCT that recruited patients who underwent RAMIE or MIE for
squamous cell esophageal carcinoma disclosed a shorter operative time and more extensive
lymphadenectomy after RAMIE. The morbidity and mortality rates were comparable between the two
groups. The long-term results of this trial, as well as the results of the ROBOT-2 and REVATE RCTs are
eagerly awaited [31-33] [Table 2].

With regards to the anastomotic leak rates, these seem to be in favour of the reconstructions using
mechanical staplers compared to the hand-sewn technique. In fact, the robotic hand-sewn anastomosis
presented the highest leak rate in a recent analysis (11.1%), whereas circular stapling resulted in 8.6% and
[23]
the linear in 4.5%, respectively . Furthermore, the use of indocyanine green (ICG) fluorescence imaging
has been demonstrated during minimally invasive and robotic esophageal resections as a technology that
may enlighten the status of the microvascular perfusion of the gastric conduit and decrease the rates of
anastomotic leakage of cervical or intrathoracic anastomoses [34-36] . In fact, a recent study showed that the
findings after the injection of ICG imaging during robotic esophagectomy guided and modified the
decision-making of surgeons on the conduit site selection in 80% of the cases analysed . In another
[36]
prospectively designed study, the decision about the optimal location of the anastomosis was changed in
14% of the cases based on the ICG findings . Whether this technological asset has the potential to affect the
[37]
anastomotic leak rate and overall morbidity of esophagectomy significantly remains to be seen in future
studies.

International meetings and discussions are key in further improving the anastomotic technique and
[6]
decreasing the conduit ischemia and overall surgical complications . A recent consensus among experts
underlined the importance of a minimum diameter of 4-5 cm of the gastric conduit, minimising the
retraction of the esophageal stump and the gastric conduit, selectively applying an omental wrap to cover
the anastomosis, occasionally performing an intraoperative leak test, and, most importantly, gradually
implementing the linear over the circular stapler. Three reasons were stated for that recommendation: first
of all, a side-to-side anastomosis is at a lower risk of ischemia; secondly, many esophageal surgeons are
familiar with linear stapling applied in bariatric procedures and using the same technique may accelerate the
learning curve; finally, totally MIE or RAMIE is not easily feasible taking into consideration the insertion of
the circular stapler through the chest wall .
[28]
Optimising the perioperative care and nutritional support of the patient undergoing esophageal resection is
also key in improving the surgical outcomes. More precisely, given that oral intake may be delayed during
the first postoperative days and that enteral nutrition is considered to be the preferable feeding route, the
use of nasogastric and jejunal feeding tubes is strongly recommended to achieve the nutritional target. The
significance of this approach is supported by the Enhanced Recovery After Surgery (ERAS) society .
[38]
Moreover, combining both oral and jejunal -through the jejunostomy tube- feeding after discharge has
shown promising results in terms of nutritional supplementation and energy levels .
[39]