Surgical resection remains the most important curative treatment
modality for non metastatic esophageal cancer. Historically, two
approaches to esophagectomy have coexisted: the transhiatal
esophagectomy (THE) and the transthoracic esophagectomy (TTE). The
mortality rate in the open era ranged between 3 and 10% and the
5-year-survival rate was 20-30%. Recent years have seen an improvement
in the outcomes due to several facts, such as improved patient care and
selection with improvement in perioperative care, neoadjuvant treatments
and centralization of surgery in high-volume centres.
Minimally invasive esophagectomy (MIE) was developed in the 1990s and
was popularized in the last decade. Several meta-analyses support the
following concepts:
- Minimally invasive esophagectomy is associated with fewer respiratory complications.
- MIE is associated with a reduction in morbidity.
- MIE is associated with faster postoperative recovery.
Nonetheless, MIE is technically demanding and programs to introduce the technique are needed.
Two classic trials, the TIME-trial (comparing thoraco-laparoscopic vs
open esophagectomy) and the MIRO-trial (laparoscopic + thoracotomy vs
open esophagectomy) have shown that MIE is associated with:
- Less blood loss.
- Lower rate of respiratory infection.
- Shorter hospital stay.
- Better quality of life.
The quality of the specimen seems comparable between open and MIE
techniques in radicality and number of lymph nodes. Long term
oncological outcomes (from the TIME-trial) showed no differences at
1-year and 3-years.
OPEN APPROACH
Transthoracic esophagectomy
The distal esophagus and its locoregional lymph nodes in the
posterior mediastinum are dissected through an upper abdominal incision.
The upper abdominal lymph nodes (including paracardial, lesser
curvature and left gastric artery) are dissected and a D1+ or D2
lymphadenectomy is performed. Via a left cervical incision, the cervical
esophagus is dissected and the intrathoracic esophagus is dissected
bluntly and stripped. A gastric tube is made and positioned in the
prevertebral plane to create an anastomosis in the neck.
Transthoracic esophagectomy
There are several techniques using a transthoracic esophagectomy:
- Ivor-Lewis: right thoracotomy and laparotomy.
- McKeown: three stage with neck incision.
- Sweet: left thoraco-abdominal incision.
Both three and two stage esophagectomies involve esophageal
resection, creation of a gastric tube, two field lymphadenectomy (celiac
trunk and mediastinum) and a cervical anastomosis in three stage
esophagectomy and intrathoracic anastomosis in Ivor-Lewis.
Differences between approaches
The HIVES trial comparing TTE with THE showed no differences
regarding in-hospital mortality but higher postoperative complications
in the TTE group (pulmonary complications and chyle leakage) with longer
postoperative hospital stay. Although there was not a statistically
significant difference in 5-year survival, it was 29% in the THE group
and 39% in the TTE group. Nonetheless,when the tumor was located in the
distal esophagus rather than the esophagogastric junction, an absolute
survival benefit of 14% was seen with the TTE. Moreover, in patients
with one to eight positive nodes in the resection specimen, 5 year
locoregional disease free survival favored the TTE (64% vs 23%). With
this data, we can conclude that patients with distal esophageal cancer
and limited nodal burden may benefit from a more extensive nodal
dissection via a TTE.
MINIMALLY INVASIVE ESOPHAGECTOMY (MIE)
Recent studies have shown that lymph node yield and surgical margins
are similar and perhaps superior with MIE compared to open approaches
(TIME-trial and MIRO-trial). The main disadvantage of MIE is that it is
technically challenging and needs careful introduction via a structured
program.
Minimally invasive esophagectomy is associated with less operative
trauma and consequently less morbidity. Fewer pulmonary complications
are reported during thoracoscopy compared to thoracotomy and, if the
prone position is used, omitting complete lung block, even fewer
pulmonary complications are expected. In laparoscopic transhiatal
dissection there is probably less manipulation and retraction of the
mediastinum and thus, fewer hemodynamic complications.
FUTURE RESEARCH
There are some ongoing randomized controlled trials comparing open
esophagectomy with the thoracoscopic approach assisted by robot (ROBOT
trial) and there are also RCTs that will compare MIE with open and
hybrid techniques (ROMIO trial). Other trials will compare the McKeown
and Ivor-Lewis MIE procedures (ICAN trial).
