Minimally invasive esophagectomy with two-field lymphadenectomy

Abstract

Curative surgical therapy for esophagogastric cancer has three fundamental principles: (1) resection of part or all of the affected organs (esophagus, stomach) with adequate clearance of the primary tumor, (2) removal of local and regional lymph nodes to eliminate potential metastatic disease, and (3) restoration of gastrointestinal continuity with satisfactory function. During the past century, a wide variety of different techniques in pursuit of these principles have been described, but to date no consensus has been reached as to which approach is ideal. Radical resections involving a thoracotomy and laparotomy in theory offer the greatest chance for long-term disease-free survival but are associated with substantial morbidity and significant impairment of postsurgical quality of life [1]. Less invasive techniques, although perhaps better tolerated, may fail to achieve the same oncologic goals. With the advancement of videoscopic technology and its application to surgery from the late 1990s onward, the concept of a minimally invasive resection using thoracoscopic and laparoscopic rather than open approaches has been an attractive aim. The intention is to achieve a curative resection but with substantially less surgical trauma relating to operative access. Initial enthusiasm was, however, dampened when early case series reported only limited success in achieving these aims. Not until the experience described by Luketich et al. [2] did it become apparent that minimally invasive esophagectomy (MIO) might offer a viable alternative to traditional open surgery. The Exeter technique of MIO, based heavily on that described by Luketich et al. [2], offers a thoracoscopic, laparoscopic esophagectomy with two-field, radical lymph node clearance. Our initial experience confirms that this procedure can be performed successfully with low operative mortality and morbidity as well as good short-term outcomes [3].