Robotic-assisted approach to esophageal duplication cysts

Introduction

Since the introduction of minimally invasive surgical techniques in the 1990s, traditional open surgery has been replaced with approaches that involve smaller incisions, decreased post operative pain, shorter hospital length of stay, quicker recovery and fewer complications (1,2). In the United States, the da Vinci robot (Intuitive Surgical, Sunnyvale, CA, USA) was approved for use in general surgery by the Food and Drug Administration in the year 2000. Since that time, the robotic platform has been widely adopted in the field of thoracic surgery. Robotic-assisted surgery offers the advantages of improved visualization, precision and the dexterity of wristed endoinstruments. These advantages are of particular interest in foregut surgery where proper identification of tissue planes and meticulous dissection are paramount. Additionally, since esophageal surgery often requires operating in multiple anatomic fields, a minimally invasive approach is advantageous in avoiding multiple large incisions. Robotic-assisted surgery has been described in both benign and malignant foregut disease with excellent outcomes. In this review, we aim to describe robotic-assisted approaches to excision of esophageal duplication cysts.

Robotic-assisted excision of esophageal duplication cysts

Duplication cysts of the esophagus are congenital anomalies that constitute between 0.5% and 2.5% of all esophageal masses (3). Duplication cysts lay within the esophageal wall and are categorized as an intramural lesion. They share a common wall with the esophagus and approximately 80% do not communicate directly with the esophageal lumen (4,5). Patients with esophageal duplication cysts are usually asymptomatic and are often times diagnosed as an incidental finding. For those patients who are symptomatic, clinical presentation depends on the size and location of the cyst. The majority of esophageal duplication cysts are found in the lower third of the esophagus and can lead to dysphagia, food impaction and emesis. Cysts in the upper or middle third of the esophagus are associated with respiratory manifestations including stridor, dyspnea and cough.

For accurate diagnosis, computed tomography (CT) scans with intravenous contrast assists in differentiating an esophageal duplication cyst from bronchogenic cysts or other intramural lesions. A barium esophagram is helpful in delineating the esophageal anatomy and assessing for mucosal irregularities. During esophagogastroscopy, esophageal duplication cysts usually appear as submucosal lesions with normal mucosa (6). Fine needle aspiration during endoscopic ultrasound is associated with an infection rate of up to 14%, for which routine biopsy of these lesions is not recommended (7).

Once the diagnosis of an esophageal duplication cyst has been made, a discussion with patients regarding the risks and benefits of surgical excision is recommended. Surgery should be considered for symptomatic and asymptomatic patients given the risk of future complications and possible malignant transformation (8,9). Minimally-invasive approaches including video-assisted thoracoscopic surgery (VATS) and laparoscopy have been demonstrated to be feasible, safe, and with excellent outcomes (10,11). Robotic-assisted approaches can be implemented both in a trans-thoracic as well as trans-abdominal approach and the improved visualization can offer advantages of a more precise and meticulous dissection (12).

The location of the esophageal duplication cyst dictates whether a cervical, trans-thoracic or trans-abdominal approach is utilized. Regardless of the anatomic field, the basic surgical principles for excision remain the same. In order to identify the base of the cyst, a myotomy is performed using either blunt spreading or low thermal energy. Cyst rupture during the dissection is not uncommon. The myotomy is extended proximally and distally to fully evaluate the cyst in its entirety. The cyst is then enucleated with either an endoscopic linear cutting stapler, as shown in Figure 1, or thermal energy. During the enucleation, there is high risk of mucosal entry and great care must be taken to avoid an inadvertent injury. Intraoperative evaluation with endoscopy and water and air tight test can be utilized to assess mucosal integrity. For those patients who develop a focal perforation of the mucosa during dissection, this can be directly repaired using absorbable sutures. An image of the final myotomy after cyst excision is shown in Figure 2. While we routinely leave a 28 French chest tube in place at the conclusion of a trans-thoracic approach, we do not routinely leave a drain after a trans-abdominal approach; drain placement depends on surgeon preference. Post-operatively, we perform an esophagram on post-operative day 1, prior to beginning a liquid diet. This practice appears to be variable in the literature with other authors beginning a regular diet on post-operative day 1 without prior imaging (12).

Figure 1 Intraoperative view of robotic-assisted cyst excision using an endoscopic linear cutting stapler.

Figure 2 Representative image of the intrathoracic esophagus after the myotomy was performed using the robotic platform.

Conclusions

Esophageal duplication cysts are rare congenital anomalies whose treatment is surgical excision. Esophageal surgery requires meticulous dissection and careful and proper identification of tissue planes. While both thoracoscopic and laparoscopic approaches afford the operator tactile feedback, robotic-assisted surgery has many advantages including improved visualization, precision and dexterity. These benefits are particularly applicable in esophageal surgery whether in the thoracic cavity or in the subdiaphragmatic space. The robotic platform has been demonstrated to be safe and effective in the treatment of both malignant and benign foregut disease. Nevertheless, these benefits are often associated with higher costs and controversy remains if these benefits translate into improved patient outcomes. Further studies are needed to assess the cost-effectiveness of robotic-assisted surgery, demonstrate the learning curve associated with the robotic platform and the clinical benefit to patients undergoing esophageal surgery.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://aoe.amegroups.org/article/view/10.21037/aoe-24-14/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.org/article/view/10.21037/aoe-24-14/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this article and accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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