BACKGROUND: Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly adopted in centers worldwide, with ongoing refinements to enhance results. This study aims to assess the current state of RAMIE worldwide and to identify potential areas for improvement. METHODS: This descriptive study analyzed prospective data from esophageal cancer patients who underwent transthoracic RAMIE in Upper GI International Robotic Association (UGIRA) centers. Main endpoints included textbook outcome rate, surgical techniques, and perioperative outcomes. Analyses were performed separately for intrathoracic (Ivor-Lewis) and cervical anastomosis (McKeown), divided into three time cohorts (2016-2018, 2019-2020, 2021-2023). A sensitivity analysis was conducted with cases after the learning curve (> 70 cases). RESULTS: Across 28 UGIRA centers, 2012 Ivor-Lewis and 1180 McKeown procedures were performed. Over the time cohorts, textbook outcome rates were 39%, 48%, and 49% for Ivor-Lewis, and 49%, 63%, and 61% for McKeown procedures, respectively. Fully robotic procedures accounted for 66%, 51%, and 60% of Ivor-Lewis procedures, and 53%, 81%, and 66% of McKeown procedures. Lymph node yield showed 27, 30, and 30 nodes in Ivor-Lewis procedures, and 26, 26, and 34 nodes in McKeown procedures. Furthermore, high mediastinal lymphadenectomy was performed in 65%, 43%, and 37%, and 70%, 48%, and 64% of Ivor-Lewis and McKeown procedures, respectively. Anastomotic leakage rates were 22%, 22%, and 16% in Ivor-Lewis cases, and 14%, 12%, and 11% in McKeown cases. Hospital stay was 13, 14, and 13 days for Ivor-Lewis procedures, and 12, 9, and 11 days for McKeown procedures. In Ivor-Lewis and McKeown, respectively, the sensitivity analysis revealed textbook outcome rates of 43%, 54%, and 51%, and 47%, 64%, and 64%; anastomotic leakage rates of 28%, 18%, and 15%, and 13%, 11%, and 10%; and hospital stay of 11, 12, and 12 days, and 10, 9, and 9 days. CONCLUSIONS: This study demonstrates favorable outcomes over time in achieving textbook outcome after RAMIE. Areas for improvement include a reduction of anastomotic leakage and shortening of hospital stay.

Amsterdam UMC Location University of Amsterdam Amsterdam The Netherlands

Cancer Center Amsterdam Amsterdam The Netherlands

Chang Gung Memorial Hospital Linko Chang Gung University Taoyuan Taiwan

Department of Gastrointestinal Surgery Oslo University Hospital and Institute of Clinical Medicine University of Oslo Oslo Norway

Faculty of Medicine The Chinese University of Hong Kong Hong Kong SAR China

Federico 2 University of Naples Naples Italy

Israelitisches Krankenhaus Hamburg Hamburg Germany

Montpellier Cancer Institute Montpellier France

Motol University Hospital 1st Faculty of Medicine Charles University Prague Czech Republic

National Cancer Center Hospital East Chiba Japan

National Cancer Center Hospital Tokyo Japan

Portsmouth Hospitals NHS Trust Portsmouth UK

Royal Victoria Infirmary Newcastle Upon Tyne Newcastle upon Tyne UK

Ruijin Hospital Shanghai Jiao Tong University School of Medicine Shanghai China

Shanghai Chest Hospital Shanghai Jiao Tong University School of Medicine Shanghai China

St Franziskus Hospital Münster Germany

Univ Lille CNRS Inserm CHU Lille UMR9020 U1277 CANTHER Cancer Heterogeneity Plasticity and Resistance to Therapies Lille France

Universitätsklinikum Münster Münster Germany

University Digestive Healthcare Basel Switzerland

University Hospital Magdeburg Magdeburg Germany

University Hospital of Bonn Bonn Germany

University Medical Center Groningen University of Groningen Groningen The Netherlands

University Medical Center of the Johannes Gutenberg University Mainz Germany

University Medical Center Utrecht University Utrecht Utrecht The Netherlands

University of Cologne Cologne Germany

University of São Paulo São Paulo Brazil

University of Texas Southwestern Medical Center Dallas TX USA

University of Verona Verona Italy

University Pittsburgh Medical Center Pittsburgh PA USA

ZGT Almelo Almelo The Netherlands

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