Since the initial description of laparoscopic fundoplication in 1991,1 there has been continued interest in minimally invasive approaches to esophageal disease. While proponents of minimally invasive surgery claim decreases in perioperative pain and length of stay, critics often express concerns over compromised outcomes, prolonged operating times, and increased cost. However, numerous reports have documented that for both gastroesophageal (GE) reflux and achalasia,2,3 the laparoscopic approach offers equal efficacy and safety as well as decreased recovery times compared with traditional open surgery. These reports and the benefits of minimally invasive surgery perceived by the general public have increased referrals to surgeons who offer these approaches to esophageal disorders, even though alternative medical therapies are available.4,5
Although laparoscopic approaches for many benign conditions involving the distal esophagus and GE junction are now standard of care, this is not necessarily the case for minimally invasive approaches to the thoracic esophagus. This is particularly true for esophageal cancer. Concerns regarding the high degree of technical complexity, significant operator learning curves, reproducibility of outcomes in lower-volume centers, and equivalence of oncologic outcomes are at the forefront of the discussion. Despite evolving techniques and improvements in both the transhiatal and Ivor Lewis surgical approaches, esophagectomies are complex operations that are associated with significant morbidity and mortality. Furthermore, surgical candidates are often elderly patients with coexisting medical comorbidities, including respiratory and cardiovascular diseases. Nationwide, the mortality rates from esophagectomies range from 8% in high-volume centers to as high as 23% in low-volume centers.6
The application of minimally invasive surgery to complex cases may offer several potential benefits. First, open esophagectomy, even in experienced centers, continues to be associated with a significant morbidity, lengthy hospital stay, and delay in returning to preoperative activities.7 This high complication rate along with the disappointing 25% 5-year survival rate after esophagectomy has led to ongoing concern over the role of surgery in the treatment of esophageal cancer. Consequently, for some patients, alternative approaches such as definitive chemoradiation alone, palliative photodynamic therapy, or stents may be chosen by health care providers. Minimally invasive approaches to esophagectomy that promise to decrease perioperative morbidity and allow for faster postoperative recovery are, therefore, appealing to patients and referring physicians. The caveat, however, is that the minimally invasive approach should not compromise operative technique or oncologic and functional outcomes.
There has been a significant evolution in technique since the initial descriptions of hybrid approaches to esophagectomy that employed thoracoscopic esophageal mobilization with a laparotomy.8–10 Although no randomized studies of minimally invasive esophagectomy (MIE) have been performed, experience in our first 222 patients has suggested that MIE is associated with a complication rate and mortality lower than most reports of open esophagectomy.11 In our experience, a minimally invasive approach reduces postoperative pain and pulmonary complications while comparing favorably to the best published open series with regard to morbidity, mortality, and oncologic outcomes. In addition, we and others ...