Minimally invasive surgery for esophageal disease

Abstract

Surgical treatment for esophageal cancer has made great progress in the past decades. With improvement in surgical techniques and peri-operative care, esophagectomy has been made safe. In specialized centers, mortality rate of less than 5% is achieved. Morbidity rates remain high. The invasive surgery, especially with extended lymphadenectomy, performed on an elderly population with co-morbidities, has its associated complications. Survival after treatment has improved, especially with increasing use of multimodality strategies. Minimally invasive surgery in the form of video-assisted thoracoscopic (VATS) +/- laparoscopic esophagectomy, has gained popularity and has become standard in many specialized institutions. Some debatable aspects of minimally invasive esophagectomy remain; including its appropriate indication, lateral position vs. prone position, whether an intrathoracic or cervical esophageal anastomosis should be performed, and whether laparoscopic gastric mobilization should be an integral part of the procedure in addition to VATS, and if so, should the gastric conduit be prepared intra-corporeally or extra-corporeally. Its safety and applicability in the context of multimodality treatment, especially when bilateral recurrent laryngeal nerve nodal dissection is concerned, is controversial. Only one European multicenter randomized trial has been conducted comparing minimally invasive esophagectomy and open transthoracic resection. Less pulmonary complications were found. Most benign diseases of the esophagus can be dealt with by minimally invasive methods. Achalasia and other motility disorders of the esophagus have been treated with VATS approach or more commonly, laparoscopic myotomy with partial fundoplication. Leiomyoma / GIST of the esophagus can be resected using a VATS approach. Advances in endoscopic technology have found alternative strategies, including POEM and Submucosal Tunnel Endoscopic Resection (STER), expanding on the role of endoscopy in the treatment of early mucosal cancers by EMR or ESD for early mucosal cancers.