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.

Abstract Background Gastric cancer remains a major global health burden, with persistently high mortality rates despite advances in multimodal treatment. Total gastrectomy (TG) constitutes a cornerstone of curative therapy; however, the factors governing early postoperative survival remain incompletely characterized. This study aimed to identify clinical and pathological predictors of 1-year overall survival (OS) following curative-intent TG, with particular emphasis on the oncological treatment strategy and tumor regression grade (TRG). Methods We retrospectively analyzed 145 patients who underwent TG between 2012 and 2023, excluding n = 4 adjuvant-only cases. To avoid statistical collinearity, multivariable Cox proportional hazards regression was performed in two sequential steps: Model 1 assessed the treatment strategy across the overall cohort (N = 145), while Model 2 evaluated TRG exclusively within the neoadjuvant-treated subgroup (n = 85). Both models incorporated the lymph node ratio (LNR) and surgical approach, and were adjusted for resection margin status (R-status), comorbidity burden (CCI), and severe postoperative complications (Clavien-Dindo ≥ III). A 60-day landmark analysis was conducted to mitigate immortal time bias. Results Completion of the perioperative chemotherapy sequence was independently associated with significantly improved 1-year OS compared to neoadjuvant therapy alone (HR = 0.20; 95% CI, 0.08–0.50; p = 0.001). This survival advantage remained highly significant in the 60-day landmark analysis (p = 0.004). Notably, 55.3% of patients who initiated neoadjuvant chemotherapy did not proceed to the adjuvant phase, primarily owing to patient refusal or medical contraindications. When evaluated exclusively within the neoadjuvant-treated subgroup, a poorer TRG demonstrated a prognostic trend toward decreased survival (HR = 1.60; 95% CI, 0.98–2.59; p = 0.059). Although severe complications (CD ≥ III) occurred in 55.9% of patients, their incidence did not differ significantly across treatment groups (p = 0.894) and did not diminish the independent prognostic value of treatment completion. The surgical approach (robotic vs. open) exerted no significant effect on 1-year OS (HR = 0.88; p = 0.745). Conclusions Completion of the perioperative chemotherapy sequence and a favorable TRG represent two distinct and critical determinants of 1-year survival following TG for gastric cancer. While residual selection bias inherent to retrospective analyses must be acknowledged, the prognostic advantage conferred by treatment completion remains robust after adjustment for surgical morbidity, R-status, and immortal time bias. These findings underscore the prognostic importance of treatment adherence and tumor chemosensitivity, and highlight the need for individualized perioperative management strategies.

BACKGROUND:Anastomotic leakage (AL) remains one of the most feared complications after esophagectomy. Preemptive endoscopic vacuum therapy (pEVT) has been proposed to support anastomotic healing, but robust clinical data remain limited. This study aimed to evaluate the role of pEVT in the management of AL. METHODS:A retrospective cohort study analyzed 116 esophageal cancer patients who experienced AL after Ivor Lewis esophagectomy between 2012 and 2023. The patients were categorized into two groups: those who received therapeutic EVT (tEVT) after AL diagnosis without prior pEVT and those who experienced AL despite receiving pEVT and subsequently required tEVT as well. Clinical outcomes, leak severity, and hospital metrics were compared with a focus on endoscopic management of AL. RESULTS:The patients in the pEVT group presented with significantly less severe leaks (ZACC grade II: 36.7% vs. 5.4%; p < 0.001), required less intracavitary therapy (43.4% vs. 67.9%; p = 0.027), and exhibited lower postoperative inflammation. Preemptive EVT was independently associated with favorable leak grading (odds ratio, 14.4; p = 0.004), a 69% reduced need for intracavitary treatment (p = 0.027), and markedly shorter intensive care unit (ICU: -74.4%; p < 0.001) and hospital (-27.5%; p = 0.011) stays. The overall healing rate was high in both groups (pEVT: 85%; non-pEVT: 80.4%). CONCLUSIONS:Preemptive EVT significantly reduces the clinical severity of AL and facilitates faster recovery by shortening ICU and hospital stays. These findings highlight its value as a preventive strategy for high-risk patients undergoing esophagectomy. Prospective studies are needed to validate these promising results.

Comprehensive learning curve analyses across the evolution from open to robot-assisted esophagectomy remain limited. This retrospective single-center study analyzed 376 consecutive Ivor Lewis esophagectomies (2012–2023) across three eras: open (n = 127), hybrid-open (n = 52), and robot-assisted minimally invasive esophagectomy (RAMIE, n = 197). Learning curves were assessed using CUSUM analysis, and patient-specific factors were evaluated to guide case selection. Open esophagectomy reached plateau at case 65 with subsequent outcome deterioration. Hybrid-open achieved early plateau (case 15) but showed fluctuating metrics. RAMIE demonstrated steady improvement with CUSUM-derived stabilization achieved at cases 45–50 (hybrid-RAMIE) and 70 (total RAMIE), showing significant reductions in operative times, hospital stay, and ICU stay (p < 0.001). Higher BMI, advanced nodal disease, and comorbidity burden negatively impacted outcomes. In our center, CUSUM-derived stabilization was observed after approximately 45–50 cases for hybrid-RAMIE and about 70 cases for total RAMIE. Strategic case selection—prioritizing lower BMI, limited nodal burden, and minimal comorbidities may accelerate early stabilization of performance. High-volume centers may benefit from total-robotic approaches, while lower-volume programs may favor hybrid pathways.

Esophageal cancer is a global burden, and multiple international societies exist to address the issue in international collaboration. This study aims to analyze the characteristics of esophageal cancer and robot-assisted minimally invasive esophagectomy (RAMIE) across geographic areas. We performed a retrospective analysis of the Upper GI International Robotic Association (UGIRA) international database from January 2016 to April 2024. Forty centers worldwide that were known to perform RAMIE were involved in establishing this consortium. The patient characteristics, surgical techniques, and short-term outcomes of RAMIE were compared by each regional area (Europe, Asia, North America, and South America). A total of 3,916 RAMIE cases were registered in the UGIRA database (2,643 in Europe, 1,130 in Asia, 111 in North America, and 32 in South America). The median age was 66 years, and 80.5% of patients were male. Notably, Asia had a high prevalence of squamous cell carcinoma (91.2%) and predominant use of the McKeown approach (94.9%). BMI was lower in Asia, whereas comorbidities were more common in Western countries across all types. The use of neoadjuvant chemotherapy and radiation was lower in Asia (48.2% and 20.8 %, respectively). Postoperative complications also differed by region; pneumonia was most common in Europe and South America, cardiopulmonary complications in North America, and recurrent nerve injury in Asia. In conclusion, regional differences were observed in baseline characteristics, treatment approaches, and complication patterns in patients treated by RAMIE for esophageal cancer. Recognizing these variations is essential for fostering mutual understanding and advancing the field through international collaboration.

BACKGROUND/AIM:Minimal-invasive techniques have been increasingly performed to treat pancreatic lesions. We evaluated the differences between open and robotic approach for distal pancreatectomy (DP) in terms of postoperative analgesic consumption and perioperative outcomes. PATIENTS AND METHODS:Clinicopathological data of patients undergoing DP from 2012-2023 were evaluated. The study compared robotic (RDP) with open distal pancreatectomies (ODP) regarding total postoperative morphine consumption. Secondary endpoints included intensive care unit (ICU) stay and hospital stay. RESULTS:During the study period, 78 DP were performed, including, 24 RDP and 54 ODP. Multivisceral resections including DP and laparoscopic DP were excluded. Patients who underwent RDP required significantly less opioid analgesics compared to those after ODP (113.60 mg; 0,00-516,20 mg morphine milligram equivalents; median; minimum-maximum vs. 253.75 mg; 15,00-3519,45 mg; p<0.001). When adjusted for patient weight, the morphine equivalent dose also showed a significant difference between RDP and ODP (1.51; 0,00-6,53 mg/kg vs. 3.19; 0,24-62,85 mg/kg; p=0.004). Additionally, patients who underwent RDP had significantly shorter postoperative ICU stay compared to patients with ODP (0; 0-7 days vs. 4; 1-54 days; p<0.001) and shorter hospital stay compared to the open group (10.5; 6-33 days vs. 16; 9-92 days; p<0.001). CONCLUSION:Patients who underwent RDP required significantly lower amounts of opioid analgesics compared to ODP. Furthermore, RDP was associated with significantly shorter length of ICU and hospital stay.

Gastroesophageal Reflux Disease (GERD) is a condition, which is frequently encountered by gastroenterologists, otorhinolaryngologists, surgeons and general physicians and requires a multidisciplinary treatment when there is a high symptom burden in patients. Besides lower oesophageal sphincter (LES) dysfunction there are several other risk factors that contribute to the development and symptoms (worsening) of GERD. While these lifestyle modifications and pharmacological therapies, particularly proton pump inhibitors (PPIs), are first-line treatments, a subset of patients requires surgical intervention due to refractory symptoms or complications. This review traces the evolution of anti-reflux surgery, examining its historical milestones, advancements, and future prospects. This review discusses the epidemiology of GERD, its pathophysiology, but also the development of Anti-Reflux Surgery (ARS). We will discuss the available evidence regarding different ARS procedures and will focus on individualised treatment for patients with GERD. In the treatment of patients with GERD we have to take into account that it might be challenging to personalise treatment and therefore optimise results. In this instance special considerations need to be taken for patients with GERD and obesity, patients with Barretts oesophagus, patients after bariatric and metabolic surgery (BMS) and patients with oesophageal motility disorders. Gastroesophageal Reflux Disease (GERD) is a condition, which is frequently encountered and requires a multidisciplinary treatment. Lifestyle modifications and pharmacological therapies are first-line treatments. Surgery is often required due to refractory symptoms or complications. In the treatment of patients with GERD we have to take into account that it might be challenging to personalise treatment and therefore optimise results. Special considerations need to be taken for patients with GERD and obesity, patients with Barretts oesophagus, patients after bariatric and metabolic surgery (BMS) and patients with oesophageal motility disorders.

Background:Hepatocellular carcinoma (HCC) is associated with high recurrence rates despite curative-intent liver resection. This necessitates improved prognostic tools and novel therapeutic strategies, including immune checkpoint inhibitors (ICIs). Circulating stem cells (CSCs) have emerged as potential prognostic biomarkers. Aim:To assess the prognostic relevance of CSCs expressing programmed death-ligand 1 (PD-L1+CSCs) in relation to recurrence-free survival (RFS) and overall survival (OS) in patients undergoing surgery for HCC. Methods:PD-L1+CSCs (CD45-/CD146+/ASGPR+/CD90+/PD-L1+) were analyzed in 27 HCC patients before surgery, immediately after surgery, and at 6 and 12 months after surgery using fluorescence-activated cell sorting and immunofluorescence microscopy. Tumor recurrence was monitored biannually through alpha-fetoprotein (AFP) measurements and imaging (CT/MRI). Control groups included patients with benign liver disease, non-HCC malignancies, and healthy donors. Results:Before surgery, 29.7% (8/27) of HCC patients had detectable PD-L1+CSCs. Postoperatively, their frequency initially declined to 22.3%, followed by a significant rise to 85% at six months and 88% at twelve months (both p < 0.01). Increasing postoperative PD-L1+CSC levels were associated with tumor recurrence (51.8%). The presence of preoperative PD-L1+CSCs correlated with reduced OS (p = 0.05) and shorter RFS (p = 0.07). Conclusion:PD-L1+CSCs are associated with poor oncological outcomes and represent promising prognostic and therapeutic targets in HCC.

BACKGROUND: Hepatocellular carcinoma (HCC) has a high recurrence rate even after curative hepatectomy. Circulating tumor cells (CTCs) have emerged as promising liquid biopsy biomarkers for minimal residual disease and early recurrence. This study evaluated longitudinal CTC dynamics and their prognostic significance in HCC patients undergoing curative resection. METHODS: We prospectively analyzed CTCs in 27 HCC patients at four time points: preoperatively, immediately postoperatively, and at 6 and 12 months after surgery. CTCs were defined as CD45⁻/CD146⁺/ASGPR⁺ using multicolor flow cytometry and immunofluorescence. Recurrence-free survival (RFS) and overall survival (OS) were assessed during a median 3.7-year follow-up. Control groups included 29 patients with non-malignant or non-HCC liver tumors and 8 healthy donors. RESULTS: Preoperative CTCs were detected in 48.2% of HCC patients (mean 0.46 cells/mL). Detection rates rose to 95% at 6 months and 100% at 12 months post-surgery. Persistent or rising postoperative CTCs were strongly associated with early recurrence (51.8% overall) and reduced RFS (p = 0.02) and OS (p = 0.05). No significant correlation was observed between CTC levels and tumor size or volume, AFP, or IL-6 levels. CONCLUSIONS: Longitudinal CTC monitoring provides an early and non-invasive indicator of recurrence risk and survival after curative HCC resection. Persistent CTCs may represent minimal residual disease and a potential therapeutic target for improving long-term outcomes.

Abstract Robotic surgery has expanded minimally invasive options but introduces specific vulnerabilities during intraoperative emergencies. The physical separation of the surgeon from the patient, restricted access due to docking, and dependence on complex technology can delay life‑saving interventions if teams are not prepared. This review summarizes current evidence and expert practice on emergency management along the perioperative pathway in robotic surgery, focusing on a structured, systems‑based salvage strategy. Key domains include preoperative planning, classification of recoverable and non‑recoverable errors, and standardized protocols for rapid undocking, conversion, hemorrhage control, and resuscitation. Particular emphasis is placed on human factors, including visible name tags, closed‑loop communication, and structured briefings to strengthen situational awareness and role clarity in crises. Simulation‑based curricula and high‑fidelity in situ drills are highlighted as essential for rehearsing rare but high‑impact events such as catastrophic bleeding, cardiorespiratory collapse, or robotic system failure. In parallel, technology‑driven tools such as surgeon‑controlled suction, advanced vessel sealing, and artificial‑intelligence–assisted monitoring are discussed as adjuncts for earlier recognition and standardized documentation of critical events. Integrating these elements into protocolized workflows can improve preparedness, shorten response times, and support safer decision‑making when seconds matter in robotic surgery.

Background: According to current guidelines, preoperative endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting (ERCP/stenting) is often necessary in patients with obstructive jaundice due to pancreatic ductal adenocarcinoma (PDAC), including severe jaundice (bilirubin > 250 umol/l), pruritus, cholangitis, cholestatic liver dysfunction, renal failure, severe malnutrition, or delayed surgery for tumors requiring neoadjuvant chemotherapy. We aimed to investigate the impact of preoperative ERCP/stenting on postoperative and long-term outcomes following pancreaticoduodenectomy (PD) for PDAC. Methods: Clinicopathological data of patients who underwent partial/total PD for PDAC between 2012 and 2019 in two hepato-pancreato-biliary centers in Germany and Switzerland were assessed. We compared patients treated with preoperative ERCP/stenting with those directly undergoing surgery according to postoperative morbidity, postoperative mortality, overall survival (OS) and disease-free survival (DFS). Results: During the study period, 192 patients underwent partial/total PD for PDAC. ERCP/stenting was performed in 105 patients, and 87 patients underwent resection without prior intervention. Postoperative 90-day overall morbidity rate (71% vs. 56%, p = 0.029) and superficial surgical site infection (SSI) rate (39% vs. 17%, p < 0.001) were significantly worse following preoperative ERCP/stenting. Major postoperative morbidity rate (18% vs. 21%, p = 0.650), organ/space SSI rate (7% vs. 14%, p = 0.100), and 90-day postoperative mortality rate (4% vs. 2%, p = 0.549) did not significantly differ between the two groups. After excluding 44 patients for whom the indication for ERCP/stenting was not consistent with current guidelines, ERCP/stenting was associated with a higher superficial SSI rate (36% vs. 17%, p = 0.009) and shorter length of stay (12 vs. 16 days, p = 0.004). Median OS (ERCP/stenting: 18 months vs. no ERCP/stenting: 23 months, p = 0.490) and median DFS (ERCP/stenting: 14 months vs. no ERCP/stenting: 18 months, p = 0.645) were independent from the utilization of ERCP/stenting. Conclusions: Preoperative ERCP/stenting in patients with PDAC can be performed without increasing organ/space SSI, major perioperative morbidity, and mortality rates and without worsening oncologic outcomes. However, it is associated with higher superficial SSI rates. If ERCP/stenting is not performed routinely but according to current guidelines, it is also associated with a shorter length of hospital stay. Further refinement of the indications for preoperative ERCP/stenting may reduce superficial SSI rates.

Cancer surgery accounts for a substantial proportion of allogeneic blood use. As demographic changes lead to a growing number of oncologic procedures, transfusion demands are increasing, while blood supply shortages persist. Moreover, allogeneic blood transfusions carry inherent risks, especially in cancer patients, due to potential transfusion-associated immunomodulatory effects.Intraoperative cell salvage (IOCS) potentially presents a promising strategy to reduce allogeneic transfusions. However, its application in oncologic surgery remains controversial due to the theoretical risk of reinfusing viable tumor cells. Techniques to mitigate this risk include the use of leukocyte depletion filters, irradiation, and antibody-based treatments. Nonetheless, the exact oncologic burden of salvaged blood, in terms of tumor cell quantity, viability, proliferative capacity, migratory behavior, and metastatic potential, remains insufficiently characterized.Meta-analyses of observational studies suggest that oncologic outcomes in patients treated with IOCS are comparable to or better than those of patients treated with allogeneic blood transfusions. Yet, randomized controlled trials have not been performed yet due to missing preclinical evidence.This review aims to summarize the current evidence on the biology of remaining tumor cells in salvaged blood, evaluate the effectiveness of existing cell reduction strategies, and highlight key methodological challenges in quantifying and characterizing residual malignant cells. In addition, we spotlight recent advances in laboratory assays designed to detect circulating tumor cells (CTCs) in blood, particularly technologies developed for the analysis of intravascular CTCs. Given their similar methodological principles, these technologies offer promising tools for future safety assessments of IOCS in oncologic surgery.

Surgical training persists of intensive work, incessant practice, and, most importantly, experience. Owing to the changing surgical environment, increasing specialization, and rapid development of minimally invasive techniques, new innovative approaches in surgical training are necessary to achieve excellent postgraduate education. Here, we introduce a surgical skills lab that offers a multi-course program featuring a concise, modular curriculum comprising well-defined and simple-to-follow procedures, progressively moving surgical techniques from ex vivo to in vivo settings. The evaluation of the course was conducted by analyzing the participants’ self-assessment before and after the course. Over the time of ten years, we conducted one-day surgical training courses covering basic surgical techniques, gastrointestinal anastomosis, visceral resection techniques, and techniques in vascular surgery with a total of 348 participants. To assess differences in the self-evaluation of surgical skills before and after each course, a questionnaire (non-validated self-report 5-point Likert scale) was administered to each participant. Results were analyzed with t-test for paired samples. Before the course, most participants had no practical knowledge of most exercises, and major help was needed. However, after training, the majority of participants were able to perform the surgical techniques independently with little or no assistance. Moreover, a statistical analysis comparing pre- and post-course self-assessment scores for surgical skills revealed significant improvements (p < 0.05) after the course. During the one-day course, it was possible to teach and perform diverse surgical procedures under the guidance of experienced surgeons. The independent reproducibility of the learned material after the course is not yet known, therefore, further investigation is necessary to provide additional information to improve the program. However, with this step-by-step training, we were able to conduct a successful teaching program, shown by the fact that the participants showed significant improvement. Thus, the training presented in this study can serve as a guide for teaching surgical skills outside of the operating room.

Gastric cancer requires surgical resection for cure, with robot-assisted minimally invasive gastrectomy (RAMIG) emerging as an alternative to open gastrectomy (OG). Comparative data on postoperative pain and recovery remain limited. This study aimed to compare RAMIG versus OG in patients with resectable gastric cancer, focusing on postoperative opioid consumption, pain intensity, and recovery parameters. In this retrospective cohort study, 138 patients with resectable gastric cancer underwent either RAMIG (n = 39) or OG (n = 99) between May 2021 and August 2023. Primary endpoints were pain intensity (Numerical Rating Scale (NRS)) and opioid consumption. Secondary endpoints comprised intensive/intermediate care (ICU/IMC) and hospital stays, blood loss, severe complications, and operative duration. Statistical analysis used SPSS version 29.0 with Mann–Whitney U and Fisher’s exact tests (p < 0.05). RAMIG showed reduced opioid consumption (p = 0.002) and lower NRS scores during mobilization on days 5 and 7 (p = 0.011; p = 0.002) and at rest on day 7 (p = 0.005). The RAMIG group experienced significantly shortened ICU/IMC stays (p < 0.001), reduced hospitalization duration (p < 0.001), and decreased intraoperative blood loss, although operative duration was prolonged. RAMIG demonstrates favorable outcomes regarding opioid requirements, pain management, ICU/IMC and hospital stays, and blood loss compared to OG, despite longer operative duration. These findings support RAMIG as an effective approach enabling accelerated recovery in patient-centered care, though prospective randomized validation studies are warranted. Trial registration: DRKS00036368, retrospectively registered 11th of March 2025.

Background: The focus of this research is to examine the growing use of robotic-assisted minimally invasive esophagectomy. Specifically, it evaluates the immediate clinical and cancer-related results of combining robotic-assisted minimally invasive esophagectomy with a systematic approach to total mesoesophageal excision, as opposed to traditional open transthoracic esophagectomy methods that do not employ a structured total mesoesophageal excision protocol. Methods: A propensity score-matched analysis of 185 robotic-assisted minimally invasive esophagectomies and 223 open transthoracic esophagectomies after standardized Ivor Lewis esophagectomy was performed. After 1:1 nearest neighbor matching to account for confounding by covariates, outcomes of 181 robotic-assisted minimally invasive esophagectomy and 181 open transthoracic esophagectomy were compared. Results: The patient characteristics showed significant differences in the age distribution and in comorbidities such as coronary heart disease, arterial hypertension, and anticoagulant intake. The R0-resection rate of robotic-assisted minimally invasive esophagectomy (96.7%) was significantly higher than open transthoracic esophagectomy (89.0%, P = .004). Thirty-day mortality and hospital mortality showed no significant differences. Postoperative pneumonia rate after robotic-assisted minimally invasive esophagectomy (12.7%) was significantly reduced (open transthoracic esophagectomy 28.7%, P < .001). Robotic-assisted minimally invasive esophagectomy had a significantly shorter intensive care unit stay (P < .001) and shorter hospital stay (P < .001). Conclusion: This single-center, retrospective study employing propensity score matching found that combining robotic-assisted minimally invasive esophagectomy with structured total mesoesophageal excision results in better short-term clinical and oncologic outcomes than open transthoracic esophagectomy. This finding is significant because the increased rate of R0 resection could indicate a higher likelihood of improved long-term survival. Additionally, enhanced overall postoperative recovery may contribute to better risk management in esophagectomy procedures. (c) 2024 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Esophageal surgery is deemed one of the most complex visceral operations. There is a well-documented correlation between higher caseload and better outcomes, with hospitals that perform more surgeries experiencing significantly lower mortality rates. The approach to caseload per year varies across different countries within Europe. Germany increased the minimum annual required caseload of complex esophageal surgeries from 10 to 26 starting in 2023. Furthermore, the new regulations present challenges for surgical training and staff recruitment, risking the further fragmentation of training programs. Enhanced regional cooperation is proposed as a solution to ensure comprehensive training. This review explores the benefits of robotic-assisted minimally invasive esophagectomy (RAMIE) in improving surgical precision and patient outcomes and aims to evaluate how the caseload per year influences the quality of patient care and the efficacy of surgical training, especially with the integration of advanced robotic techniques.

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. 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). Across 28 UGIRA centers, 2012 Ivor–Lewis and 1180 McKeown procedures were performed. Over the time cohorts, textbook outcome rates were 39