Profile of a perfect outcome (clavien dindo 0) after robotic-assisted minimally invasive Ivor-lewis esophagectomy (RAMIE)

Abstract Objectives Robotic assisted minimally invasive esophagectomy (RAMIE) has demonstrated advantages over open esophagectomy, including reduced morbidity and comparable oncological outcomes. However, predicting which patients achieve a “perfect outcome” remains unclear. This study evaluates postoperative outcomes in RAMIE patients and identifies parameters associated with an uncomplicated recovery in a German high-volume center. Methods We conducted a retrospective analysis of 249 RAMIE cases performed between April 2017 and January 2023. Patients were divided into two groups: Clavien-Dindo grade 0(n=87) and Clavien-Dindo>0(n=162). Preoperative demographics, intraoperative metrics, and postoperative outcomes were compared. Key postoperative metrics included ICU/hospital stay duration, removal of catheters, initiation of oral feeding, and C-reactive protein (CRP) levels on postoperative days (POD) 3, 5, and 7. Results No significant differences were found in preoperative factors. Intraoperative parameters, including operative time and single-lung ventilation duration, were similar between groups. CRP levels were significantly lower in complication-free patients on POD3 (105.7 vs. 132.6 mg/L; p=0.0009), POD5 (66.0 vs.130.0 mg/L; p<0.0001), and POD7 (44.1 vs. 111.4 mg/L; p<0.0001). Patients with a perfect outcome had earlier removal of peridural catheters (POD6 vs.POD8; p=0.0021), chest drains (POD6 vs. POD7; p=0.0009), and initiation of oral feeding (POD6 vs. POD9; p<0.0001). Importantly, 66 % of complications occurred before POD6. Conclusions A perfect outcome following RAMIE is associated with earlier catheter removal, and oral feeding initiation by POD6, alongside CRP levels below 70 mg/L. The sixth postoperative day appears pivotal for predicting outcomes, as complications predominantly manifest before this timeframe. These findings highlight the importance of targeted postoperative management to identify low-risk patients suitable for early discharge, improving recovery and resource utilization.