Robotic Transhiatal Revision of Gastric Conduit after Esophagectomy

S. KIM¹, J. Luketich², E. Gutierrez³, Y. Suzuki¹, G. Lloyd¹, A. Pennathur⁴, O. Awais⁵, R. Levy³, E. Tatsuya. Alicuben^6
1University of Pittsburgh Medical Center, PITTSBURGH, Pennsylvania ²UPMC Presbyterian, Pittsburgh, Pennsylvania ³UPMC, pittsburgh, Pennsylvania ⁴University of Pittsburgh Medical Center - Department of Cardiothoraci, Pittsburgh, Pennsylvania ⁵UPMC Mercy Hospital, Pittsburgh, Pennsylvania ⁶University of Pittsburgh Medical Center, OAKMONT, Pennsylvania

Purpose: The literature offers limited insight into post-esophagectomy revision strategies, which typically involve open or combined thoracoscopic-laparoscopic approaches. We present our institution's early experience with robot-assisted transhiatal revisional surgery for severe gastric conduit dysfunction following esophagectomy.

Methods: We conducted a retrospective, single-institution review of patients who underwent robot-assisted laparoscopic revisional surgery after esophagectomy between January 2010 and April 2024. Our study focused on cases where robotic transhiatal revision was the initial revision following the index esophagectomy.
The robotic transhiatal conduit revision, performed entirely through laparoscopic incisions, involves several important steps: intra-abdominal adhesiolysis, diaphragmatic and hiatal mobilization, high mediastinal and conduit mobilization, para-conduit hernia reduction, conduit restapling, and hiatal closure with conduit-pexy. (Figure 1) This procedure aims to reconstruct an anatomy closely resembling the native esophageal structure by repositioning the conduit within the mediastinum, reshaping it into a narrow, straight tubular conduit, and creating an optimal sub-diaphragmatic antral reservoir.

Results: 15 patients underwent robot-assisted transhiatal revisional surgery for severe gastric conduit dysfunction following esophagectomy. The mean age of patients was 64.1 years. The majority (66.7%) had initially undergone esophagectomy for benign esophageal pathologies after failed achalasia or anti-reflux operations, while 33.3% had esophagectomy for cancer. Most patients (86.7%) had undergone Ivor Lewis esophagectomy, with 93.3% of all procedures being minimally invasive. The median time from index esophagectomy to revision was 62 months. Preoperative evaluation revealed para-conduit herniation in 53.3%, redundant conduit in 53.3%, and conduit angulation with shelving in 66.7% of patients. All patients presented with dysphagia, while 46.7% reported nausea/vomiting and 20% had severe weight loss requiring tube feeding. Perioperatively, one patient developed pulmonary embolism, and one experienced port-site herniation requiring surgical fixation. (Table 1) The average length of stay was 6.4 days. There was one perioperative mortality due to sudden death at home after an unremarkable 4-day hospital stay. At a median follow-up of 5.3 months, all surviving patients (n=14) reported at least partial symptom resolution and restored PO intake. However, 50% still experienced residual dysphagia, 35.7% required post-revisional EGD with dilation for symptomatic relief, and one patient underwent redo-revision due to recurred para-conduit herniation after vigorous coughing.

Conclusion: Robot-assisted transhiatal revisional surgery is a promising, minimally invasive technique to address severe gastric conduit dysfunction post-esophagectomy. Although the procedure may help alleviate symptoms in most patients, complete symptom resolution remains difficult, and perioperative risks continue to exist. Future research is needed to refine surgical techniques, optimize patient selection criteria, and develop standardized post-operative protocols to enhance perioperative outcomes and durable quality of life in this challenging patient cohort.

Identify the source of the funding for this research project: none