PROSPERO

International prospective register of systematic reviews

The clinical outcomes of robotic-assisted minimally invasive esophagectomy: a

comprehensive meta-analysis
Dali Chen, Jing-hai Zhou, Bo Deng, Qun-you Tan

Citation
Dali Chen, Jing-hai Zhou, Bo Deng, Qun-you Tan. The clinical outcomes of robotic-assisted
minimally invasive esophagectomy: a comprehensive meta-analysis. PROSPERO 2017
CRD42017071263 Available from:
http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017071263

Review question
This meta-analysis is conducted to evaluate various sorts of clinical outcomes of robotic-assisted minimally
invasive esophagectomy (RAMIE) compared to open esophagectomy (OE) and minimally invasive
esophagectomy without robotic assistance (MIE).

Searches
We will search for studies from the following electronic sources: PubMed, the Cochrane Central Register of
Controlled Trials (CENTRAL) (Cochrane Library), EMBASE (1980 to present) (Ovid), Web of Science, the
Chinese Biomedical Literature Database (CBM), National Institute of Health Clinical Trials Database, WHO
International Clinical Trials Registry Platform (ICTRP). In addition, we will perform supplementary literature
retrieval by searching the reference list of included studies.

Search strategy
https://www.ncbi.nlm.nih.gov/pubmed?term=(esophagectomy)%20AND%20robotic

Types of study to be included

The randomized controlled trials (RCTs) are the priority of our meta-analysis. If not, clinical controlled studies
either prospectively or retrospectively will be included in the present meta-analysis. They should comply with
the following comparative principle: RAMIE was compared with OE or MIE. Clinical studies without control
group will be excluded.

Condition or domain being studied

Since the receipt of US Food and Drug Administration approval in 2000, the da Vinci surgical system
(Intuitive Surgical, Sunnyvale, Calif) which is the leading robotic assistance during minimally invasive surgical
has been widely applied in multiple specialties including esophagectomy. Numerous types of clinical study
such as case series, controlled study and cohort related to robotic-assisted minimally invasive
esophagectomy (RAMIE) have been reported. Meredith K et al. have reported retrospective data of 147
patients undergoing RAMIE. They demonstrated that RAMIE is a safe and feasible surgical technique that
provides an alternative to minimally invasive and open techniques. Abbott A and colleagues further
evaluated the impact of age on outcomes in patients undergoing RAMIE. No statistically significant difference
exists in operative time, length of hospitalization, adverse events, or mortality. Their study demonstrated that
RAMIE can be safely used in senior population. In addition, Goel A et al. implied that RAMIE is a safe and
feasible surgical technique even in patients who have undergone preoperative neoadjuvant chemoradiation.
It is acknowledged that open esophagectomy (OE) may bring about severe surgical damage and result in
delayed postoperative recovery. RAMIE, as one type of minimally invasive esophagectomy, can perfectly
overcome the defects of OE. However, it also has some weaknesses such as higher expenditure, and longer
learn curve, which limit it to be widely generalized. Therefore, clinical studies related to clinical effects of
RAMIE are limited in number and their sample size is usually small, which lead to devalue the evidence of
these studies. Even though some relative reviews or systemic reviews have been published, it is necessary
for us to implement a comprehensively meta-analysis to quantitatively evaluate the clinical outcomes of

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International prospective register of systematic reviews

RAMIE compared with OE and minimally invasive esophagectomy without robotic assistance (MIE).

Participants/population
Robotic group: patients suffered from esophageal diseases (either malignant or benign diseases) with
scheduled robotic-assisted minimally invasive esophagectomy (RAMIE). Patients would be included in
robotic group as long as the robotic surgical system was used during the operation. Controlled group:
patients suffered from esophageal diseases (either malignant or benign diseases) with scheduled open
esophagectomy (OE) or minimally invasive esophagectomy without robotic assistance (MIE).

Intervention(s), exposure(s)
If the robotic surgical system was reported to be applied during the operation, this surgical procedure is
defined as RAMIE. There was great variability in surgical approaches, including robotic transthoracic and/or
transhiatal approaches with or without thoracoscopy, laparoscopy, or laparotomy, with variations in
positioning including supine, lateral, and prone.

Comparator(s)/control
The controlled group are patients with scheduled open esophagectomy (OE) or minimally invasive
esophagectomy without robotic assistance (MIE).

Primary outcome(s)
Surgery related outcomes e.g. operative time, estimated blood loss during the surgery, length of hospital stay
(from operation to discharge), length of stay in the intensive care unit (ICU).

Secondary outcome(s)
1. Oncological outcomes e.g. number of dissected lymph nodes, survival data.
2. Complications e.g. hospital mortality, anastomotic leakage, pulmonary complications.

Data extraction (selection and coding)

Risk of bias (quality) assessment
The quality of eligible studies was assessed by two authors independently. The risk of bias of RCTs will be
evaluated according to the criteria of Cochrane Handbook for Systemic Reviews of Interventions. The quality
of other types of controlled studies will be assessed using Newcastle-Ottawa Quality Assessment Scale
(Case Control Studies). We will resolve any disagreement by consultation.

Strategy for data synthesis

The heterogenety among included articles was examed by Chi-square and I-square tests. The homogeneity
was defined as I-square < 50% and P value > 0.05, on the contrary, it was regarded as heterogeneity. If
hetergeneity exists, subgroup analysis or meta-regression would be used to identify its potential factors and
random effective model would be used to conduct the pooled meta-analysis. In addition, fix effective model
would be used to conduct the pooled meta-analysis when homogeneity was abtained. For most of variations
in this meta-analysis, the relative risk (RR) or weight mean deviation (WMD) were used to summarize the
results of enumeration data or measurement data, respectively. The hazard ratio (HR) was chosen as the
appropriate summary statistic for survival data. The potential publication bias was evaluated by Egger’s test,
P > 0.05 indicates no potential publication bias. Meta-analysis and publication biases were both performed
by STATA 11.0 (STATA Corporation, College Station, TX).

Analysis of subgroups or subsets

If necessary, we will perform subgroup analysis according to disease types, nations, publication year and so
on.

Contact details for further information

Dali Chen
chendali1989@sina.cn

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International prospective register of systematic reviews

Organisational affiliation of the review

Daping Hospital and the Research Institute of Surgery, the Third Military Medical University
www.dph-fsi.com

Review team members and their organisational affiliations

Dr Dali Chen. The Department of Thoracic Surgery, Daping Hospital and the Research Institute of Surgery,
the Third Military Medical University, Chongqing, China
Professor Jing-hai Zhou. The Department of Thoracic Surgery, Daping Hospital and the Research Institute of
Surgery, the Third Military Medical University, Chongqing, China
Professor Bo Deng. The Department of Thoracic Surgery, Daping Hospital and the Research Institute of
Surgery, the Third Military Medical University, Chongqing, China
Professor Qun-you Tan. The Department of Thoracic Surgery, Daping Hospital and the Research Institute of
Surgery, the Third Military Medical University, Chongqing, China

Anticipated or actual start date

25 June 2017

Anticipated completion date

31 July 2017

Funding sources/sponsors
None

Conflicts of interest
None known

Language
English

Country
China

Stage of review
Review_Ongoing

Subject index terms status

Subject indexing assigned by CRD

Subject index terms

Esophagectomy; Esophageal Neoplasms; Humans; Minimally Invasive Surgical Procedures; Robotics

Date of registration in PROSPERO

05 July 2017

Date of publication of this version

05 July 2017

Details of any existing review of the same topic by the same authors
Stage of review at time of this submission

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International prospective register of systematic reviews

Stage Started Completed

Preliminary searches Yes Yes
Piloting of the study selection process Yes Yes

Formal screening of search results against eligibility criteria Yes Yes

Data extraction Yes No

Risk of bias (quality) assessment Yes No

Data analysis Yes No

Versions
05 July 2017

PROSPERO
This information has been provided by the named contact for this review. CRD has accepted this information in good
faith and registered the review in PROSPERO. CRD bears no responsibility or liability for the content of this registration
record, any associated files or external websites.

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