Minimally Invasive Esophagectomy
The incidence of esophageal cancer has increased over the last several decades, and adenocarcinoma now surpasses the incidence of squamous cell carcinoma. Treatment of esophageal carcinoma has become more aggressive and effective, and the overall morbidity and mortality in those who are surgically treated have declined, approaching 8-11% and 40-50%, respectively. [1, 2]
The history of esophageal disease and its surgical treatment dates back to 2500 BCE in ancient civilizations. However, it was not until the 17th century that the first cervical esophagotomy was reported; in the latter part of the 19th century, the first cervical esophagectomy was performed by Johann Nepomuk Czerny. 
In 1913, Franz Torek, a German-born surgeon, performed the first thoracic esophagectomy for cancer in the German (now Lenox Hill) Hospital in New York City. Although advised against performing such a procedure, Torek was successful in part because of the recent developments in intratracheal anesthesia and asepsis.  Over the next several decades, open surgical esophagectomy developed as an acceptable treatment for benign disease as well as esophageal cancer.
In 1989, interest in laparoscopic surgical techniques was sparked, as the first laparoscopic cholecystectomy was performed.  This technique was first adapted into the field of esophageal disease in 1991 with laparoscopic fundoplication, performed by Dallemagne et al.  With this, the shift toward minimally invasive esophageal surgery began.
Traditional approaches via open transhiatal or transthoracic (Ivor Lewis) resections were first “hybridized” with minimally invasive techniques, where parts of the procedure were performed in a minimally invasive fashion and other parts via standard incisions. 
Dallemagne et al performed the first mini-invasive subtotal esophagectomy in 1992, using both thoracoscopy (for dissecting the esophagus) and laparoscopy (for the gastroplasty).  The first esophagectomy performed completely via laparoscopy through a transhiatal approach was in 1995 by DePaul et al.  In 1999, Watson et al described a completely minimally invasive Ivor Lewis technique.  Subsequently, robotic-assisted approaches were described [11, 12] (see the video below).
Traditionally, esophagectomy has been performed via open transthoracic or transhiatal approaches, with randomized trials showing no significant difference in overall survival or disease-free survival. Furthermore, outcomes in minimally invasive esophagectomy (MIE) compare favorably to the reported series of open esophagectomy. 
Minimally invasive approaches to treatment of benign esophageal diseases have been met with widespread acceptance. This includes diseases such as achalasia, paraesophageal hernia, and other complex esophageal disorders. [14, 15, 16, 17] This has not been the case with malignant disease of the esophagus. Currently, no criteria define when a minimally invasive procedure should be performed in preference to an open procedure.  However, there is growing support for the feasibility of employing MIE in esophageal cancer. 
An increasing trend exists for many high-volume institutions to use MIE in treatment of Barrett disease with high-grade dysplasia and in patients with small resectable lesions that have limited nodal involvement (N0-1). This includes T1 (invasion of the lamina propria or submucosa), T2 (invasion of the muscularis propria), and some instances of T3 lesions (invasion of the adventitia). Neoadjuvant chemoradiation is not a contraindication for MIE. [20, 21] For more information, see Esophageal Cancer Guidelines.
Currently, no standardized contraindications exist regarding the use of MIE. However, T4 lesions (invasion of surrounding tissues) are generally not amenable to any form of surgical resection. Extensive nodal disease and metastatic disease are also advanced stages that may require an open surgical approach or even endoscopic stenting for palliation instead of an attempt at MIE.  Furthermore, any patient with a lesion that bridges the esophagogastric junction may not be considered a candidate for this approach unless the gastric margin can be cleared and an esophagogastrectomy can be done either via open approach or minimally invasively.
As with other laparoscopic procedures, patients with extensive adhesions and scar tissue over the abdomen or chest wall, particularly in areas where the thoracoscope or laparoscope would be placed, are a higher-risk group for treatment with MIE. Older patients and those with comorbid conditions are not candidates for surgery, because of the high morbidity with either an MIE or a standard procedure, but they may benefit more from nonsurgical therapy. 
Minimally invasive techniques for esophageal resection have been reported to have acceptably reduced procedure-related morbidity without compromising disease-free survival rates. 
Luketich et al have an extensive reported experience; their initial series of 222 patients has grown to more than 1000.  In the initial series, mortality was 1.4% versus 5.5% for an open approach. [22, 24, 25] Furthermore, the survival curve at 19-month follow-up was comparable in the two groups.  In their 2012 report of 1011 patients who underwent MIE via either a modified McKeown minimally invasive approach or an MIE Ivor Lewis approach, the authors cited a 0.9% mortality for the MIE Ivor Lewis approach. 
In another analysis of 41 elderly patients over the age of 75 years who underwent minimally invasive esophagectomy, no operative deaths occurred, with a survival of 81% at 20 month follow-up.  These findings suggest that MIE can be safely performed in selected patients and even those considered high-risk that might not otherwise be considered for an open surgery.
Other outcome improvements seen with minimally invasive esophagectomy include decreased ICU and hospital length of stay, decreased blood loss, and operating times. In particular, Luketich et al reported a median ICU stay of 1 day and a total length of hospital stay of 7 days, compared with the average hospital stay of 16.6 days in the open approach. Operating room times in the same study averaged 306 minutes, whereas the average for an open procedure is 336 minutes. [22, 24] Similar results can be seen in multiple other series as compared to open procedures (see the table below).
Complications and outcomes are significantly influenced by the volume of patients, because a large learning curve exists. High-volume centers tend to have more experience and, therefore, better outcomes than smaller-volume hospitals.
Wang et al carried out a propensity score-matched comparison of MIE and open esophagectomy with respect to outcomes, quality of life, and survival in patients with squamous cell carcinoma.  They found that MIE was associated with a shorter operating time (191 ± 47 minutes vs 211 ± 44 minutes), reduced blood loss (135 ± 74 mL vs 163 ± 84 mL), a similar lymph node harvest (24.1 ± 6.2 vs 24.3 ± 6.0), a shorter postoperative hospital stay (11 days vs 12 days), a lower rate of major complications (30.4% vs 36.9%), a lower rate of readmission to the intensive care unit (ICU; 5.6% vs 9.7%), and comparable perioperative mortality.
van der Sluis et al assessed the long-term oncologic results of robot-assisted minimally invasive thoracolaparoscopic esophagectomy (RAMIE) with two-field lymphadenectomy in 108 patients with potentially resectable esophageal cancer.  They found RAMIE to be oncologically effective and capable of providing good local control with a low percentage of local recurrence at long-term follow-up.
In a prospective phase II study (coordinated by the Eastern Cooperative Oncology Group) aimed at assessing the feasibility of MIE in a multi-institutional setting, Luketich et al reported the following results  :
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Michael Scott Halbreiner, MD Resident Physician, Clinical Instructor, Department of Surgery, The School of Medicine at Stony Brook University Medical Center
Disclosure: Nothing to disclose.
Kevin T Watkins, MD Chief, Division of Upper Gastrointestinal and General Surgical Oncology, Director, Upper Gastrointestinal Cancer Management Team, Stony Brook University Medical Center; Associate Professor of Surgery, The School of Medicine at Stony Brook University Medical Center
Kevin T Watkins, MD is a member of the following medical societies: International Hepato-Pancreato-Biliary Association, Society of American Gastrointestinal and Endoscopic Surgeons, SWOG, Americas Hepato-Pancreato-Biliary Association, American College of Surgeons Oncology Group
Disclosure: Nothing to disclose.
Allison J McLarty, MD Associate Professor of Surgery, The School of Medicine at Stony Brook University Medical Center; Associate Program Director, Department of Surgery, Codirector of Ventricular Assist Device Program, Stony Brook University Medical Center; Director of Thoracic Surgery, Northport Veterans Affairs Medical Center
Allison J McLarty, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Medical Association, Medical Society of the State of New York, Society of Thoracic Surgeons
Disclosure: Nothing to disclose.
Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine
Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.
Minimally Invasive Esophagectomy
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