# Changing Complication Profiles in the Era of Robotic Ivor Lewis Esophagectomy: A Comparative Analysis of Open, Hybrid, and Fully Robotic Techniques

## TL;DR

Robotic esophagectomy improves cancer surgery outcomes but has unique risks like higher chylothorax rates, which may be linked to more extensive lymph node removal.

## Contribution

The study identifies a new complication profile specific to robotic esophagectomy, particularly increased chylothorax due to radical lymphadenectomy.

## Key findings

- Fully robotic surgery had a 12.4% chylothorax rate compared to 2.5% in open surgery.
- Robotic approaches reduced neo-esophagus–airway fistulas to 0.6% from 4.9% in open surgery.
- Lymphatic leakage in chylothorax cases originated from abdominal lymphadenectomy, not thoracic duct injury.

## Abstract

Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly used in esophageal cancer surgery because it improves surgical precision and facilitates more extensive lymphadenectomy. However, robotic surgery may also be associated with a distinct complication profile. In this retrospective single-center study, we analyzed 407 consecutive patients undergoing Ivor Lewis esophagectomy using open, hybrid robotic, or fully robotic techniques. We focused on three clinically relevant complications: paraconduit herniation, chylothorax, and neo-esophagus–airway fistula. Fully robotic surgery was associated with a significantly higher chylothorax rate, whereas neo-esophagus–airway fistulas occurred significantly less often compared with open surgery. Lymphangiography in persistent chylothorax cases confirmed an intact thoracic duct, suggesting transhiatal lymphatic leakage from the abdominal lymphadenectomy field rather than classical thoracic duct injury. These findings highlight procedure-specific risks and may support improved preventive strategies and postoperative management in robotic esophagectomy.

Background: Novel robotic surgical techniques have substantially improved the safety and outcomes of Ivor Lewis esophagectomy, offering greater precision, reduced surgical trauma, and more radical lymphadenectomy compared to conventional approaches. While perioperative results are increasingly promising, the adoption of robotic technology appears to be accompanied by an emerging set of procedure-specific complications not previously encountered—or encountered with different frequency—in open surgery. Understanding this evolving complication profile is essential to fully realize the oncological potential of robotic esophagectomy. Methods: This retrospective single-center study compared 407 consecutive patients undergoing Ivor Lewis esophagectomy at a high-volume center (OPE n = 163; HRB n = 75; FRB n = 169; 2012–2023) regarding three pathophysiologically motivated primary endpoints within 12 months: paraconduit herniation, chylothorax, and neo-esophagus–airway fistula. Results: One-year survival was 71.8%, 74.7%, and 82.2% (p = 0.073). Chylothorax was significantly more frequent in FRB (12.4%) than in OPE (2.5%) or HRB (2.7%) (p < 0.001), with surgical approach as sole independent predictor. Lymphangiography in three FRB patients demonstrated thoracic duct integrity in all; leakage originated from the celiac lymphadenectomy field ascending transhiatally—suggesting a distinct mechanism potentially linked to surgical radicality. All cases resolved conservatively. Neo-esophagus–airway fistula occured significantly less frequently with robotic approaches (FRB 0.6% vs. OPE 4.9%; p = 0.031). Paraconduit herniation did not differ significantly within 12 months (p = 0.272). Conclusions: The complication profile of robotic Ivor Lewis esophagectomy reflects its oncological ambition: elevated chylothorax rates may correlate with radical lymphadenectomy and represent an acceptable trade-off within a multimodal treatment strategy. Fistula risk is meaningfully reduced. These findings support robotic esophagectomy as a safe and effective approach in experienced centers.