Comparing Robot-Assisted, Minimally Invasive, Transcervical, and Transhiatal Esophagectomy for Esophageal Cancer: A Causal Deep Learning Meta-Analysis with Neural Architecture
Muhammad Allam Rafi*
This meta-analysis evaluates the effectiveness of four esophagectomy procedures—Robot-Assisted Minimally Invasive Esophagectomy (RAMIE), Minimally Invasive Esophagectomy (MIE), Transcervical Esophagectomy (TCE), and Transhiatal Esophagectomy (THE)—for treating esophageal cancer, utilizing causal deep learning techniques to assess key clinical outcomes. Data from 70,102 patients were analyzed, focusing on operative time, postoperative complications, mortality, hospital stay, and lymph node retrieval. Unlike traditional statistical methods, deep learning models capture non-linear relationships and adjust for multiple confounders, providing more accurate and reliable predictions. The results show RAMIE to be the most effective procedure, with an average operative time of 350 minutes, reduced blood loss (250 mL), and fewer complications (24%). MIE follows closely with 300 minutes of operative time, 200 mL of blood loss, and a 30% complication rate. TCE and THE have higher complication rates (up to 40% and 42%, respectively), alongside longer recovery times. THE, although less effective in clinical outcomes, proved to be more cost-efficient. SUCRA rankings confirmed RAMIE’s superiority (88%), compared to MIE (83%), TCE (76%), and THE (66%). Additionally, decision tree analysis with 95.63% accuracy and 96.17% cross-validation performance supported RAMIE as the optimal choice, highlighting its precision, fewer complications, and faster recovery, despite higher costs. This study underscores the significance of deep learning, enhancing surgical decision-making and optimizing patient outcomes, with machine learning offering a more robust and nuanced approach compared to traditional methods.
Betzler, J., Elfinger, L., Büttner, S., Weiß, C., Rahbari, N., Betzler, A., Reissfelder, C., Otto, M., Blank, S., & Schölch, S. (2022). Robot-assisted esophagectomy may improve perioperative outcome in patients with esophageal cancer – a single-center experience. Frontiers in Oncology, 12, 966321. https://doi.org/10.3389/fonc.2022.966321
Blazeby, J., & Metcalfe, C. (2023). OGC O01 Minimally invasive or open oesophagectomy for localised oesophageal cancer: long-term follow-up of the ROMIO pragmatic randomised controlled trial. British Journal of Surgery. https://doi.org/10.1093/bjs/znad348.032
Bongiolatti, S., Farronato, A., Marino, M., Annecchiarico, M., Coratti, F., Cianchi, F., Coratti, A., & Voltolini, L. (2020). Robot-assisted minimally invasive esophagectomy: systematic review on surgical and oncological outcomes. Mini-invasive Surgery. https://doi.org/10.20517/2574-1225.2020.28
Chan, K., & Oo, A. (2023). Exploring the learning curve in minimally invasive esophagectomy: a systematic review. Diseases of the Esophagus: official journal of the International Society for Diseases of the Esophagus. https://doi.org/10.1093/dote/doad008
Chao, Y., Li, Z., Jiang, H., Wen, Y., Chiu, C., Li, B., Shang, X., Fang, T., Yang, Y., Yue, J., Zhang, X., Zhang, C., & Liu, Y. (2024). Multicentre randomized clinical trial on robot-assisted versus video-assisted thoracoscopic oesophagectomy (REVATE trial). The British Journal of Surgery, 111. https://doi.org/10.1093/bjs/znae143
Esagian, S., Ziogas, I., Skarentzos, K., Katsaros, I., Tsoulfas, G., Molena, D., Karamouzis, M., Rouvelas, I., Nilsson, M., & Schizas, D. (2022). Robot-Assisted Minimally Invasive Esophagectomy versus Open Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-Analysis. Cancers, 14. https://doi.org/10.3390/cancers14133177
Erol, H., Imai, T., Murayama, K., & Erol, P. (2023). A comparative review of minimally invasive approaches to esophagectomy: technical considerations, variations, and outcomes. Mini-invasive Surgery. https://doi.org/10.20517/2574-1225.2023.82
Gong, L., Jiang, H., Yue, J., Duan, X., Tang, P., Ren, P., Zhao, X., Liu, X., Zhang, X., & Yu, Z. (2020). Comparison of the short-term outcomes of robot-assisted minimally invasive, video-assisted minimally invasive, and open esophagectomy. Journal of Thoracic Disease, 12, 224–230. https://doi.org/10.21037/jtd.2019.12.56
Grimminger, P., Staubitz, J., Perez, D., Ghadban, T., Reeh, M., Scognamiglio, P., Izbicki, J., Biebl, M., Fuchs, H., Bruns, C., Lang, H., Becker, T., & Egberts, J. (2021). Multicenter Experience in Robot-Assisted Minimally Invasive Esophagectomy — a Comparison of Hybrid and Totally Robot-Assisted Techniques. Journal of Gastrointestinal Surgery, 25, 234–245. https://doi.org/10.1007/s11605-021-05044-8
Hoelzen, J., Frankauer, B., Szardenings, C., Roy, D., Pollmann, L., Fortmann, L., Merten, J., Rijcken, E., Juratli, M., & Pascher, A. (2023). Reducing the Risks of Esophagectomies: A Retrospective Comparison of Hybrid versus Full-Robotic-Assisted Minimally Invasive Esophagectomy (RAMIE) Approaches. Journal of Clinical Medicine, 12, 185823. https://doi.org/10.3390/jcm12185823
Huang, Y., Zhao, Y., & Song, J. (2021). Early outcomes with robot-assisted vs. minimally invasive esophagectomy for esophageal cancer: a systematic review and meta-analysis of matched studies. European Review for Medical and Pharmacological Sciences, 25, 24, 7887-7897. https://doi.org/10.26355/eurrev_202112_27637
Jebril, W., Klevebro, F., Rouvelas, I., & Nilsson, M. (2021). Open, hybrid or total minimally invasive esophagectomy; a comprehensive review based on a systematic literature search. https://doi.org/10.21037/AOE-2020-03
Jha, S., Dhamija, N., Kumar, A., & Rawat, S. (2020). Robotic-assisted esophagectomy: A literature review and our experience at a tertiary care centre. Laparoscopic, Endoscopic and Robotic Surgery, 3, 74-79. https://doi.org/10.1016/j.lers.2020.06.005
Keeney-Bonthrone, T. P., Abbott, K. L., Haley, C., Karmakar, M., Hawes, A. M., Chang, A. C., Lin, J., Lynch, W. R., Carrott, P. W., Lagisetty, K. H., Orringer, M. B., & Reddy, R. M. (2022). Transhiatal robot-assisted minimally invasive esophagectomy: unclear benefits compared to traditional transhiatal esophagectomy. Journal of Robotic Surgery, 16(4). https://doi.org/10.1007/s11701-021-01311-7
Kersebaum, J., Möller, T., Becker, T., & Egberts, J. (2020). Robotic resection for esophageal cancer. European Surgery, 53, 133-141. https://doi.org/10.1007/s10353-020-00675-8
Knitter, S., Maurer, M., Winter, A., Dobrindt, E., Seika, P., Ritschl, P., Raakow, J., Pratschke, J., & Denecke, C. (2023). Robotic-Assisted Ivor Lewis Esophagectomy Is Safe and Cost Equivalent Compared to Minimally Invasive Esophagectomy in a Tertiary Referral Center. Cancers, 16, 112. https://doi.org/10.3390/cancers16010112
Mederos, M., De Virgilio, M., Shenoy, R., Ye, L., Toste, P., Mak, S., Booth, M., Begashaw, M., Wilson, M., Gunnar, W., Shekelle, P., Maggard-Gibbons, M., & Girgis, M. (2021). Comparison of Clinical Outcomes of Robot-Assisted, Video-Assisted, and Open Esophagectomy for Esophageal Cancer. JAMA Network Open, 4. https://doi.org/10.1001/jamanetworkopen.2021.29228
Nuytens, F., Dabakuyo-Yonli, T., Meunier, B., Gagnière, J., Collet, D., D'Journo, X., Brigand, C., Perniceni, T., Carrère, N., Mabrut, J., Msika, S., Peschaud, F., Prudhomme, M., Markar, S., & Piessen, G. (2021). Five-Year Survival Outcomes of Hybrid Minimally Invasive Esophagectomy in Esophageal Cancer: Results of the MIRO Randomized Clinical Trial. JAMA Surgery. https://doi.org/10.1001/jamasurg.2020.7081
Prasad, P., Wallace, L., Navidi, M., & Phillips, A. (2021). P-OGC26 Learning curves in minimally invasive esophagectomy- a systematic review and evaluation of benchmarking parameters. British Journal of Surgery. https://doi.org/10.1093/bjs/znab430.154
Sato, S., Higashizono, K., Nagai, E., Taki, Y., Nishida, M., Watanabe, M., & Oba, N. (2021). Hand-assisted robotic surgery in the abdominal phase of robot-assisted oesophagectomy. Journal of Minimally Access Surgery, 17(3), 415-417. https://doi.org/10.4103/jmas.JMAS_68_20
Shekelle, P., Toste, P., Mederos, M., Virgilio, M., Childers, C., Ye, L., Shenoy, R., & Begashaw, M. (2020). Robot-assisted Surgery for Esophageal Cancer: Analysis of Short-and Long-term Outcomes.
Shemmeri, E., & Wee, J. (2020). Robotics and minimally invasive esophageal surgery. Annals of Translational Medicine, 9. https://doi.org/10.21037/atm-20-4138
Szakó, L., Németh, D., Farkas, N., Kiss, S., Dömötör, R. Z., Engh, M. A., Hegyi, P., Eross, B., & Papp, A. (2022). Network meta-analysis of randomized controlled trials on esophagectomies in esophageal cancer: The superiority of minimally invasive surgery. World journal of gastroenterology, 28(30), 4201–4210. https://doi.org/10.3748/wjg.v28.i30.4201
Tsunoda, S., Obama, K., Hisamori, S., Nishigori, T., Okamura, R., Maekawa, H., & Sakai, Y. (2020). Lower Incidence of Postoperative Pulmonary Complications Following Robot-Assisted Minimally Invasive Esophagectomy for Esophageal Cancer: Propensity Score-Matched Comparison to Conventional Minimally Invasive Esophagectomy. Annals of Surgical Oncology, 28, 1502-1509. https://doi.org/10.1245/s10434-020-09081-6
Wang, Y., He, X., He, Y., Bao, T., Xie, X., Li, K., & Guo, W. (2023). Comparison of two different methods for lymphadenectomy along the left recurrent laryngeal nerve by minimally invasive esophagectomy in patients with esophageal squamous cell carcinoma: a prospective randomized trial. International Journal of Surgery (London, England), 110, 159-166. https://doi.org/10.1097/JS9.0000000000000788
Williams, A., Kathawate, R., Zhao, L., Grenda, T., Bergquist, C., Brescia, A., Kilbane, K., Barrett, E., Chang, A., Lynch, W., Lin, J., Wakeam, E., Lagisetty, K., Orringer, M., & Reddy, R. (2021). Similar Quality of Life After Conventional and Robotic Transhiatal Esophagectomy. The Annals of Thoracic Surgery. https://doi.org/10.1016/j.athoracsur.2021.03.018
Xue, M., Liu, J., Lu, M., Zhang, H., Liu, W., & Tian, H. (2024). Robotic assisted minimally invasive esophagectomy versus minimally invasive esophagectomy. Frontiers in Oncology, 13, 150-160. https://doi.org/10.3389/fonc.2023.1293645
Yang, Y., Li, B., Yi, J., Hua, R., Chen, H., Tan, L., Li, H., He, Y., Guo, X., Sun, Y., Yu, B., & Li, Z. (2021). Robot-assisted Versus Conventional Minimally Invasive Esophagectomy for Resectable Esophageal Squamous Cell Carcinoma. Annals of Surgery, 275, 646-653. https://doi.org/10.1097/SLA.0000000000005023
Yun, J., Chong, B., Kim, H., Lee, I., Gong, C., Kim, B., Lee, G., Choi, S., Kim, H., Kim, D., Park, S., & Kim, Y. (2020). Comparative outcomes of robot-assisted minimally invasive versus open esophagectomy in patients with esophageal squamous cell carcinoma: a propensity score-weighted analysis. Diseases of the Esophagus, 33, 8. https://doi.org/10.1093/dote/doz071
Zhang, Y., Dong, D., Cao, Y., Huang, M., Li, J., Zhang, J., Lin, J., Sarkaria, I., Toni, L., David, R., He, J., & Li, H. (2022). Robotic Versus Conventional Minimally Invasive Esophagectomy for Esophageal Cancer. Annals of Surgery, 278, 39 - 50. https://doi.org/10.1097/SLA.0000000000005782
Zeng, T., He, Y., Yuan, Z., He, Z., & Li, S. (2022). A meta-analysis of robotic-assisted esophagectomy versus conventional esophagectomy in patients with esophageal cancer. Journal of Robotic Surgery. https://doi.org/10.1007/s11701-022-01372-0
Zhang, S., & Shi, W. (2021). Robotic-assisted esophagectomy for esophageal cancer: A comprehensive systematic review and meta-analysis. Journal of Thoracic Disease, 13, 4083–4094. https://doi.org/10.21037/jtd-20-2767
Zhang, Z., Zhang, H., Yang, H., Li, Y., Li, M., Yang, Y., & Zhang, L. (2020). Comparison of Robot-assisted Minimally Invasive Esophagectomy with Traditional Open Surgery for Esophageal Cancer: A Systematic Review and Meta-analysis. Annals of Surgical Treatment and Research, 99(2), 81–88. https://doi.org/10.4174/astr.2020.99.2.81