Minimally invasive esophagectomy

Esophagectomy for carcinoma of the esophagus should include several objectives: (i) complete resection of all disease, (2) lymph node sampling or complete dissection of regional lymph nodes, and () replacement of the esophagus with a gastric or intestinal conduit with anastomosis in the upper chest or in the neck. Regardless of the surgical procedure used, avoidance of local recurrence, minimizing complications and rapid return to preoperative performance status are obvious goals. Conventional open esophagectomy is associated with significant morbidity and mortality. A recent report from a single institution for a 10-year period revealed a complication rate of 50% and a mortality rate of io% [ii. This is consistent with a more comprehensive review of the morbidity and mortality across centers in the United States, which showed the mortality rates of esophagectomy range from 8% in high volume centers to an alarming 22% in centers with low volumes of these complex cases [21. With the development of minimally invasive techniques, surgeons have accomplished reductions in the morbidity of many foregut procedures and, in some cases, made them technically easier to perform while maintaining sound surgical principles. In an effort to decrease the morbidity associated with esophagectomy, these minimally invasive techniques have been applied to resection of the esophagus. In our own experience, minimally invasive esophagectomy (MIE) appears to achieve the goals of complete resection, good functional outcomes and less morbidity. In this chapter we will review the results of our own experience with MIE and review other recent series, and discuss some of the controversies of this approach. It is important to note that many of the controversies associated with standard open esophagectomy have not been overcome, such as operative approach, radicality of the resection, conduit of choice and use of neoadjuvant therapies. These controversies continue to challenge us in the era of less invasive techniques.