Abstract
Background
Surgery for oesophageal squamous cell carcinoma involves dissecting lymph nodes along the recurrent laryngeal nerve. This is technically challenging and injury to the recurrent laryngeal nerve may lead to vocal cord palsy, which increases the risk of pulmonary complications. The aim of this study was to compare the efficacy and safety of robot-assisted oesophagectomy (RAO) versus video-assisted thoracoscopic oesophagectomy (VAO) for dissection of lymph nodes along the left RLN.
Methods
Patients with oesophageal squamous cell carcinoma who were scheduled for minimally invasive McKeown oesophagectomy were allocated randomly to RAO or VAO, stratified by centre. The primary endpoint was the success rate of left recurrent laryngeal nerve lymph node dissection. Success was defined as the removal of at least one lymph node without causing nerve damage lasting longer than 6 months. Secondary endpoints were perioperative and oncological outcomes.
Results
From June 2018 to March 2022, 212 patients from 3 centres in Asia were randomized, and 203 were included in the analysis (RAO group 103; VAO group 100). Successful left recurrent laryngeal nerve lymph node dissection was achieved in 88.3% of the RAO group and 69% of the VAO group (P < 0.001). The rate of removal of at least one lymph node according to pathology was 94.2% for the RAO and 86% for the VAO group (P = 0.051). At 1 week after surgery, the RAO group had a lower incidence of left recurrent laryngeal nerve palsy than the VAO group (20.4 versus 34%; P = 0.029); permanent recurrent laryngeal nerve palsy rates at 6 months were 5.8 and 20% respectively (P = 0.003). More mediastinal lymph nodes were dissected in the RAO group (median 16 (i.q.r. 12–22) versus 14 (10–20); P = 0.035). Postoperative complication rates were comparable between the two groups and there were no in-hospital deaths.
Conclusion
In patients with oesophageal squamous cell carcinoma, RAO leads to more successful left recurrent laryngeal nerve lymph node dissection than VAO, including a lower rate of short- and long-term recurrent laryngeal nerve injury. Registration number: NCT03713749 (http://www.clinicaltrials.gov).
The REVATE trial demonstrated that utilizing RE significantly enhanced the feasibility and safety of conducting LND along the left RLN. Furthermore, the use of RE also led to superior efficacy compared to VATE, as evidenced by reduced operating time, enhanced mediastinal lymphadenectomy, and accelerated postoperative drain removal.
Introduction
For oesophageal squamous cell carcinoma (OSCC), upper mediastinal lymph nodes located along the recurrent laryngeal nerves (RLNs) are considered nodal stations with highest incidence of metastases (23–60%)1–3. Therefore, dissection of the lymph nodes along the RLN is recommended, but there is a substantial risk of causing injury to the RLN, particularly on the left side. In Asia, where RLN lymph node dissection is often performed routinely, the rate of left RLN palsy after open surgery is reported to be as high as 28.4–58.4%4–6. Introduction of video-assisted thoracoscopic oesophagectomy (VAO) has not lowered the rate of left RLN palsy to a great extent7–11.
Injury to the RLN may result in vocal cord paralysis and aspiration-induced pulmonary complications, which are linked to increased mortality rates10,12. Therefore, completing a thorough lymph node dissection along the RLN while preventing RLN palsy during oesophagectomy remains a challenge. Robot-assisted oesophagectomy (RAO) may facilitate dissection of lymph nodes along the bilateral RLN, resulting in a reduced nerve palsy rate13–15. However, given the retrospective design of these studies, it remains unclear whether use of the robotic platform or other surgeon- or disease-related factors play a role.
Therefore, REVATE (Robotic Oesophagectomy versus Video-Assisted Thoracoscopic Esophagectomy), a multicentre RCT, was designed. The aim of the study was to compare the success of robotic and thoracoscopic lymph node dissection along the left RLN in patients with OSCC. The hypothesis was that RAO would increase the rate of successful dissection of lymph nodes along the left RLN lymph node without causing RLN palsy.
Methods
Study design and patients
REVATE was a multicentre, open-label, randomized clinical superiority trial, undertaken in three high-volume centres in Asia. The trial followed CONSORT guidelines and was conducted in accordance with the principle of the Declaration of Helsinki and Good Clinical Practice Guidelines. The participating institutions included Chang Gung Memorial Hospital-Linkou (Taiwan), Shanghai Chest Hospital (China), and Tianjin Medical University Cancer Institute and Hospital (China). All operations were carried out by experienced surgeons who had previously completed at least 50 RAO and 100 VAO procedures. The trial was approved by the institutional review boards of all participating hospitals. All participants provided written informed consent in compliance with local regulations. The REVATE trial was registered at ClinicalTrial.gov (NCT03713749). The study protocol has been published previously16.
Participants
The study focused on patients diagnosed with oesophageal cancer who required oesophagectomy. Inclusion criteria were: age between 18 and 80 years; histological diagnosis of primary intrathoracic OSCC; scheduled for McKeown minimally invasive oesophagectomy (MIO) and bilateral RLN lymph node dissection; European Clinical Oncology Group performance status 0–1; surgically resectable disease (cT1–4a N0–3 M0) according to the eighth edition of the AJCC Staging Manual; normal bilateral vocal cord function confirmed by preoperative laryngoscopic examination; and willingness to provide written informed consent. Exclusion criteria were: history of previous major thoracic surgery that prevented MIO; history of a second malignancy other than OSCC; and inability to comply with the follow-up schedule.
Randomization
Patients were asked to participate in the study by their surgeons or research staff at the outpatient clinic. After providing written informed consent, patients were randomized in a 1 : 1 ratio to either RAO or VAO using a centre-stratified randomization procedure by computer-generated random numbers. To achieve this aim, R version 3.3.3 (R Foundation for Statistical Computing, Vienna, Austria) equipped with an optional package (randomizeR) was used. Randomization was performed by a statistician who was not involved in recruitment, data collection, or treatment in the study. Randomization codes were concealed in sequentially numbered opaque envelopes to ensure allocation concealment. Patients and investigators undertaking interventions, assessing outcomes, and analysing data were not masked to the group assignment.
Surgical technique and postoperative care
All patients were scheduled for McKeown MIO with two-field (total mediastinal) lymphadenectomy. This included removal of lymph nodes along the bilateral RLN in the upper mediastinum, as well as lower mediastinal and upper abdominal lymph nodes, as the intended surgical treatment17,18. The right and left RLN nodes were referred to as nodal station 2R and 2L in the AJCC Staging Manual (8th edition) and 106recR/106recL in the Japanese Classification of Oesophageal Cancer (11th edition)19,20. The detailed technique for RLN lymph node dissection has been described previously11,21–24. The operating surgeon made the choice to omit RLN lymph node dissection under certain conditions, which were evaluated on an individual basis during surgery. These included low chance of cure indicated by tumour growth into adjacent organs (T4b status), distant metastases (M1 status) detected during surgery, and unforeseen intraoperative adverse events or findings requiring discontinuation of surgery. Other surgical variables, such as the use of laparotomy versus laparoscopy, anastomotic technique, and route of reconstruction, were not expected to affect the results of RLN lymph node dissection and were left to the surgeon’s discretion.
All patients were admitted to an ICU and transferred to a general surgical ward the following day if vital signs remained stable. Enteral tube feeding was initiated on postoperative day 1. The chest drains were removed when the drained fluid volume was consistently less than 100–250 ml per 24 h, and there were no indications of complications or air leakage. However, the volume criteria varied among centres. A barium swallow study was performed on postoperative day 7 and oral intake was started.
Data collection and variable definitions
A unique patient identification code was assigned to each study patient. Only the study coordinators had access to the list. Data collection and storage complied with Good Clinical Practice guidelines. Non-electronic data were stored securely in locked cabinets at data coordinating centres, accessible to the principal investigator, research nurses, and physicians. Each participating centre could request information from the main database, but direct access was permitted only for locally generated data. When the trial ended, data access requests were sent to the principal investigator. Completed case record forms were compared with source data to ensure the accuracy and reliability of data on primary and secondary outcome measures. All clinical records were stored securely in an anonymous manner to safeguard privacy, and all investigators strictly adhered to local confidentiality regulations.
Primary endpoint
The primary endpoint was the success rate of left RLN lymph node dissection. A successful lymph node dissection was defined by the removal of at least one lymph node along the left RLN as confirmed pathologically, without left RLN palsy lasting longer than 6 months. Vocal cord function was evaluated using a flexible laryngoscope within 1 week of surgery in all patients. RLN palsy was classified by site (unilateral versus bilateral) and duration (temporary—recovering within 6 months versus permanent—not recovering within 6 months)25. All patients diagnosed with postoperative RLN palsy underwent laryngoscopic examinations at 1, 3, and 6 months after surgery26.
Secondary endpoints
Secondary endpoints were the number of nodes removed along the right and left RLNs; pneumonia according to the Revised Uniform Pneumonia Score27; other postoperative complications according to the Esophagectomy Complications Consensus Group system28 and Clavien–Dindo classification (grade IIIa or higher defined as major); in-hospital, 30-day, and 90-day mortality, defined as deaths occurring during the same hospital stay or within 30 or 90 days after surgery respectively; R0 resection rate (microscopically negative proximal/distal and circumferential margin); surgical outcomes (duration of operation, intraoperative complications, blood loss, and conversion rate); postoperative recovery metrics; and the need for reintubation or readmission to the ICU.
Sample size calculation
The success rates of left RLN lymph node dissection were previously reported to be 70–75 and 85–90% for VAO and RAO respectively11,29. The trial was designed to demonstrate that the success rate of left RLN lymph node dissection for RAO would be at least 15% higher than that for VAO, assuming a 75% success rate for VAO. A one-sided test was used because the null hypothesis stated that the difference between the two arms was less than or equal to 15%. In this type of test, the ‘extreme’ portion of the distribution in advance was defined as being ‘sufficiently large’ (15%). Assuming an α error of 0.05 and 80% power, one-sided two-sample comparisons of proportions were conducted using a balanced trial design. Based on these calculations, a total of 95 patients would be needed in each treatment arm. Taking into account the possibility that approximately 10% of eligible patients may not undergo the allocated intervention, a total of 212 patients (106 in each arm) was needed.
Statistical analysis
The data analysis adhered to the per-protocol principles and focused on patients who received RLN lymph node dissection by the allocated intervention. For the primary outcome, a one-sided two-sample proportion test was used. Primary outcome analyses was also carried out by Cochran-Mantel-Haenszel tests taking into center effect. Categorical secondary outcomes were expressed as frequencies and compared using the Chi-square test or Fisher’s exact test. Continuous secondary outcomes are presented as either mean(s.d.) or median (i.q.r.), depending on whether the variables were distributed normally or skewed. The Shapiro–Wilk test was employed to assess the normality of variable distribution. For normally distributed data, comparisons were made using the Student’s t test, whereas the non-parametric Mann-Whitney U test was used for skewed parameters. In subgroup analyses, all subcategories were prespecified, and the results presented visually in a forest plot, including risk ratios (RRs), 95% confidence intervals, and corresponding P values. The RR was defined by the ratio of the success rate of left RLN lymph node dissection between the RAO and VAO groups. An RR greater than 1 indicated a preference for RAO, whereas an RR of less than 1 indicated a preference for VAO. To avoid inflating the probability of type I error owing to multiple comparisons, Bonferroni’s correction was applied, and the significance level was set at 0.005 for subgroup analyses. The statistical packages SAS® version 9.3 (SAS Institute, Cary, NC, USA) and SPSS® version 20.0 (IBM, Armonk, NY, USA) were used for analyses. For all calculations except subgroup analyses, P < 0.050 was considered statistically significant.
Results
Patient characteristics
Between November 2018 and March 2022, 212 of 262 eligible patients were assigned randomly to undergo either RAO (106) or VAO (106). A total of nine patients were excluded from the analysis. Among these, seven patients did not receive the planned RLN lymph node dissection because of T4b or M1 disease detected during surgery. The remaining two patients underwent RLN lymph node dissection; however, it was performed via an open approach, differing from the allocated procedure (Fig. 1). This left 103 patients in the RAO group and 100 in the VAO group for inclusion in the final analysis. The RAO and VAO groups were well balanced in terms of demographic and clinical characteristics (Table 1). The number of patients screened, excluded, and randomized from each participating centre is detailed in Table S1. The demographic and clinical characteristics of all randomized patients (106 per arm) are presented in Table S2.
Fig. 1.
CONSORT diagram for the trial
RAO, robot-assisted oesophagectomy; VAO, video-assisted thoracoscopic oesophagectomy; RLN, recurrent laryngeal nerve; LND, lymoh node dissection.
Table 1.
Patient characteristics
| Total (n = 203) |
RAO (n = 103) |
VAO (n = 100) |
|
|---|---|---|---|
| Age (years), mean(s.d.) | 60.6(8.1) | 60.0(8.4) | 61.3(7.7) |
| Sex | |||
| Male | 184 (90.6) | 96 (93.2) | 88 (88) |
| Female | 19 (9.4) | 7 (6.8) | 12 (12) |
| BMI (kg/m2), mean(s.d.) | 22.99(3.09) | 22.97(3.42) | 23.18(3.18) |
| ASA physical status grade | |||
| I | 22 (10.8) | 11 (10.7) | 11 (11) |
| II | 100 (49.3) | 51 (49.5) | 49 (49) |
| III | 81 (39.9) | 41 (39.8) | 40 (40) |
| Charlson Co-morbidity Index score | |||
| 0 | 150 (73.9) | 75 (72.8) | 75 (75) |
| 1 | 39 (19.2) | 20 (19.4) | 19 (19) |
| >1 | 14 (6.9) | 8 (7.8) | 6 (6) |
| Tumour location | |||
| Upper third | 15 (7.4) | 11 (10.7) | 4 (4) |
| Middle third | 86 (42.4) | 45 (43.7) | 41 (41) |
| Lower third | 102 (50.2) | 47 (45.6) | 55 (55) |
| Clinical stage | |||
| I | 27 (13.3) | 11 (10.7) | 16 (16) |
| II | 59 (29.1) | 31 (30.1) | 28 (28) |
| III | 94 (46.3) | 49 (47.6) | 45 (45) |
| IV | 23 (11.3) | 12 (11.7) | 11 (11) |
| Preoperative therapy | |||
| None | 103 (50.7) | 50 (48.5) | 53 (53) |
| Chemoradiotherapy | 83 (40.9) | 43 (41.7) | 40 (40) |
| Chemotherapy | 17 (8.4) | 10 (9.8) | 7 (7) |
| Abdominal phase | |||
| Open | 6 (3) | 2 (1.9) | 4 (4) |
| Minimally invasive surgery | 197 (97) | 101 (98.1) | 96 (96) |
| Neck lymph node dissection | 35 (17.2) | 14 (13.6) | 21 (21) |
| Anastomotic technique | |||
| Circular stapler | 169 (83.3) | 80 (77.7) | 89 (89) |
| Linear stapler | 34 (16.7) | 23 (22.3) | 11 (11) |
Values are n (%) unless otherwise indicated. RAO, robot-assisted oesophagectomy; VAO, video-assisted thoracoscopic oesophagectomy.
Primary endpoint
The primary endpoint of successful left RLN lymph node dissection was achieved in 91 of 103 patients (88.3%) in the RAO group and 69 of 100 (69%) in the VAO group (P < 0.001). This difference remained significant even after accounting for possible centre effects (P < 0.001, Cochran–Mantel–Haenszel test).
Table 2 shows an overview of the parameters associated with attainment of the primary endpoint. The percentage of patients in the RAO group who underwent successful left RLN removal (at least 1 lymph node according to pathology report) was 94.2% for RAO and 86% for VAO group (P = 0.051). Patients in the RAO group had a lower incidence of left RLN palsy than those in the VAO group and this difference was stable during follow-up (Fig. 2). The RLN palsy rate at 1 week was 20.4% in the RAO compared with 34% in the VAO group (P = 0.029). Permanent RLN palsy rates at 6 months were 5.8 and 20% respectively (P = 0.003). Table S3 shows the number of patients in whom left RLN lymph node dissection was not successful and the specific reasons for this.
Table 2.
Primary endpoint and related parameters
| Total (n = 203) |
RAO (n = 103) |
VAO (n = 100) |
P* | |
|---|---|---|---|---|
| Patients with no lymph nodes removed along left RLN | 20 (9.9) | 6 (5.8) | 14 (14) | 0.051 |
| Left RLN palsy | ||||
| Day 7 | 55 (27.1) | 21 (20.4) | 34 (34) | 0.029 |
| Week 4 | 53 (26.1) | 20 (19.4) | 33 (33) | 0.028 |
| Week 12 | 39 (19.2) | 13 (12.6) | 26 (26) | 0.016 |
| Week 24 | 26 (12.8) | 6 (5.8) | 20 (20) | 0.003 |
| Primary endpoint | ||||
| Successful left RLN lymph node dissection | 160 of 203 (78.8) | 91 of 103 (88.3) | 69 of 100 (69) | < 0.001* |
| < 0.001† | ||||
Values are n (%). RAO, robot-assisted oesophagectomy; VAO, video-assisted thoracoscopic oesophagectomy; RLN, recurrent laryngeal nerve. The primary endpoint was assessed with *two-sample proportion test. †Cochran-Mantel-Haenszel test. The rest were all assessed by Chi-square test.
Fig. 2.
Rate of left recurrent laryngeal nerve palsy over time
RLN, recurrent laryngeal nerve; RAO, robot-assisted oesophagectomy; VAO, video-assisted thoracoscopic oesophagectomy. P < 0.050 between groups at each time point (χ2 test).
Figure S1 shows the forest plots for the primary endpoint for patients who underwent either RAO or VAO. RAO demonstrated significant advantages over VAO in certain patient subgroups. These include men (RR 1.34, 95% c.i. 1.14 to 1.59; P < 0.001), patients with clinical stage III–IV disease (RR 1.50, 1.19 to 1.90; P < 0.001), those with lesions in the upper or middle third of the oesophagus (RR 1.37, 1.09 to 1.71; P = 0.003), and those who underwent preoperative therapy (RR 1.57, 1.19 to 2.07; P < 0.001).
Secondary endpoints
Although there was no significant difference in intraoperative blood loss between the two groups, patients who underwent RAO had a shorter operating time than those who had VAO (Table 3). The radical resection (R0) rate was comparable between groups, but RAO was associated with a larger number of dissected mediastinal nodes. The percentage of patients with an uncomplicated postoperative course was comparable after RAO and VAO (51.5 versus 53% respectively; P = 0.826).
Table 3.
Secondary endpoints
| Total (n = 203) |
RAO (n = 103) |
VAO (n = 100) |
P* | |
|---|---|---|---|---|
| Duration of operation (min), median (i.q.r.) | ||||
| Overall | 335 (280–432) | 345 (263–433) | 333.5 (295.25–419.5) | 0.455† |
| Thoracic phase | 118 (95–145) | 110 (89–137) | 124 (103.5–154) | 0.003† |
| Abdominal phase | 136 (90–178) | 135 (85–170) | 137.5 (91.25–188) | 0.193† |
| Blood loss (ml), median (i.q.r) | 150 (100–200) | 100 (50–200) | 150 (100–200) | 0.222† |
| R0 resection | 195 (96.1) | 97 (94.2) | 98 (98) | 0.280* |
| Total no. of dissected nodes median (i.q.r.) | 27 (20–35) | 29 (21–37) | 25.5 (19–33) | 0.092† |
| Mediastinum | 15 (12–21) | 16 (12–22) | 14 (10–20) | 0.035† |
| Right RLN | 2 (1–4) | 3 (1–4) | 2 (1–3) | 0.141† |
| Left RLN | 2 (1–4) | 2 (1–4) | 2 (1–4) | 0.139† |
| Abdomen | 10 (6–14) | 11 (6–15) | 9.5 (5.25–13.75) | 0.370† |
| Pathological tumour stage | 0.634 | |||
| I | 80 (39.4) | 40 (38.8) | 40 (40) | |
| II | 50 (24.6) | 27 (26.2) | 23 (23) | |
| III | 57 (28.1) | 26 (25.2) | 31 (31) | |
| IV | 16 (7.9) | 10 (9.7) | 6 (6) | |
| Normal recovery without complications | 106 (52.2) | 53 (51.5) | 53 (53) | 0.826 |
| Major complications (grade ≥ IIIa) | 57 (28.1) | 27 (26.2) | 30 (30) | 0.548 |
| Pneumonia | 28 (13.8) | 14 (13.6) | 14 (14) | 0.933 |
| Anastomotic leak | 18 (8.9) | 12 (11.7) | 6 (6) | 0.157 |
| Chylothorax | 4 (2) | 1 (1.0) | 3 (3) | 0.364* |
| Reintubation | 2 (1) | 1 (1.0) | 1 (1.0) | 1.0* |
| Duration of mechanical ventilation (min), median (i.q.r) | 61 (0–209) | 60 (0–209) | 62 (0–221.5) | 0.969† |
| mechnical ventilation > 72 h | 5 (2.5) | 3 (2.9) | 2 (2.0) | 1.0* |
| ICU readmission | 1 (0.5) | 1 (1) | 0 (0) | 1.0* |
| Duration of ICU stay (days), median (i.q.r.) | 1 (1–4) | 1 (1–3) | 1 (1–4) | 0.780† |
| Duration of drainage (days), median (i.q.r.) | 5 (3–8) | 4 (3–7) | 6 (4–9) | 0.007† |
| Duration of hospital stay (days), median (i.q.r.) | 10 (9–13) | 10 (9–13) | 11 (8.25–14) | 0.402† |
| 30-day mortality | 0 (0) | 0 (0) | 0 (0) | – |
| 90-day mortality | 1 (0.5) | 0 (0) | 1 (1) | 1.0* |
| In-hospital mortality | 0 (0) | 0 (0) | 0 (0) | – |
| Unplanned readmission | 18 (8.9) | 11 (10.7) | 7 (7) | 0.357 |
Values are n (%) unless otherwise indicated. RAO, robot-assisted oesophagectomy; VAO, video-assisted thoracoscopic oesophagectomy; RLN, recurrent laryngeal nerve. *Fisher's exact test. The rest were assessed by Chi square test. †Mann-Whitney U test.
Discussion
This RCT revealed that the use of RAO was associated with a higher success rate in lymph node dissection along the left RLN and a significantly lower incidence of permanent nerve palsy compared with VAO. Additionally, RAO was associated with a moderate reduction in operating time and an enhancement in mediastinal lymph node retrieval. Mortality rates in the trial (in-hospital mortality 0%, 90-day mortality 0.5%) were comparable to current standards30,31. Although RAO within the setting of the trial may be the preferred surgical approach for treating OSCC, it is unclear whether this would translate into a clinically important benefit for the patient.
RAO provides a magnified, three-dimensional view and seven degrees of freedom in ambidexterity, enabled by the use of a manipulator with wrist and tremor filtration capabilities. Consequently, surgeons can accurately undertake delicate lymph node dissection while protecting the RLN. Unlike in previous retrospective studies that focused on the occurrence of RLN palsy, the inability to retrieve nodes around the left RLN area was also considered a failure, in accordance with the trial definition, regardless of palsy status. This composite primary endpoint allowed a more comprehensive assessment, thereby enabling the authors to elucidate the genuine advantages of RAO over VAO. In the present study, all operations were performed by experienced, high-volume surgeons, concentrating solely on the McKeown procedure. Additionally, all participating centres had passed the learning phase, boasting over 100 RAO and 500 VAO procedures each. Another strength of the study was the outcome assessment with preoperative and postoperative routine laryngoscopy examinations, regardless of whether the patient exhibited symptoms of hoarseness. This facilitated accurate assessment of the incidence of RLN palsy over time.
Although a 14% reduction in nerve palsy rates following RAO was demonstrated, the pneumonia rate did not differ significantly between the two groups. This could have been due to high patient awareness and prompt intervention. All patients underwent immediate vocal cord examination after operation and were informed about the potential consequences of aspiration. During the study interval, injection laryngoplasty was available in one of the participating centres. Augmentation of the vocal fold provides immediate improvement in phonation and may prevent aspiration without interfering with recovery of the nerve32,33. In the present study, 11 patients with RLN palsy underwent injection laryngoplasty during the index admission. None of these patients developed pneumonia, compared with 11 of 49 who did not receive this treatment.
This trial has several limitations. First, all surgical procedures were conducted by senior surgeons in high-volume centres, which may constrain the study’s generalizability and limit its applicability to surgeons with varying experience levels. Second, intraoperative nerve monitoring was not used. Therefore, it was impossible to determine whether the nerve injury occurred during the thoracic or cervical phase of the procedure. Additionally, inclusion of only patients with OSCC may restrict the broader relevance of the findings, particularly in Western countries where adenocarcinoma predominates and RLN lymph node dissection is not yet standard practice. Third, without a cost-effectiveness analysis, it is challenging to ascertain whether robotic oesophagectomy may result in a benefit for the healthcare system. Fourth, although the present study demonstrated improvement in several short-term outcomes of lymph node dissection along the left RLN with use of VAO, it is unclear whether these benefits translate into enhanced local control or better long-term oncological outcome. Finally, as the authors included patients who may benefit most from RAO based on strict inclusion criteria, the relatively small sample size in subgroup analyses may have limited the robustness of some findings.
Supplementary Material
Acknowledgements
Y.-K.C., Z.L., and H.J. contributed equally to this work.
Contributor Information
Yin-Kai Chao, Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan.
Zhigang Li, Division of Thoracic Surgery, Shanghai Chest Hospital, Shanghai, China.
Hongjing Jiang, Department of Minimally Invasive Oesophageal Surgery, Key Laboratory of Prevention and Therapy, National Clinical Research Centre of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China.
Yu-Wen Wen, Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan; Department of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
Chen-Hung Chiu, Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan.
Bin Li, Division of Thoracic Surgery, Shanghai Chest Hospital, Shanghai, China.
Xiaobin Shang, Department of Minimally Invasive Oesophageal Surgery, Key Laboratory of Prevention and Therapy, National Clinical Research Centre of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China.
Tuan-Jen Fang, Department of Otorhinolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan.
Yang Yang, Division of Thoracic Surgery, Shanghai Chest Hospital, Shanghai, China.
Jie Yue, Department of Minimally Invasive Oesophageal Surgery, Key Laboratory of Prevention and Therapy, National Clinical Research Centre of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China.
Xiaobin Zhang, Division of Thoracic Surgery, Shanghai Chest Hospital, Shanghai, China.
Chen Zhang, Department of Minimally Invasive Oesophageal Surgery, Key Laboratory of Prevention and Therapy, National Clinical Research Centre of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China.
Yun-Hen Liu, Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan.
Funding
This work was supported financially by grants from the Chang Gung Memorial Hospital, Linkou (CMRPG3H0951, XPRPG3H0091), the Program of Shanghai Academic/Technology Research Leader (22XD1402900), and the Precision Treatment Technology for Oncology Surgery program from Tianjin Medical University Cancer Institute and Hospital (ZLWKJZZL02). Robotic surgical instruments were provided through an Intuitive Surgical Clinical Research Grant (Robot-assisted versus video-assisted thoracoscopic esophagectomy for esophageal squamous cell carcinoma: a randomized controlled trial). The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Author contributions
Yin-Kai Chao (Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing—original draft, Writing—review & editing), Zhigang Li (Data curation, Project administration, Writing—review & editing), Hongjing Jiang (Conceptualization, Data curation, Writing—review & editing), Yu-Wen Wen (Formal analysis, Methodology, Writing—review & editing), Chien-Hung Chiu (Data curation, Writing—review & editing), Bin Li (Data curation, Writing—review & editing), Xiaobin Shang (Data curation), Tuan-Jen Fang (Methodology, Project administration, Writing—review & editing), Yang Yang (Data curation), Jie Yue (Data curation), Xiao Bin Zhang (Data curation, Methodology, Project administration), Chen Zhang (Methodology, Project administration, Writing—review & editing), and Yun-Hen Liu (Investigation, Methodology, Writing—review & editing)
Disclosure
Y.-K.C. has received honoraria from Intuitive Surgical Sarl (Taiwan Branch) for speaking engagements and educational contributions. The authors declare no other conflict of interest.
Supplementary material
Supplementary material is available at BJS online.
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.