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.
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.
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.
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).