Chapter 19. Video-Assisted Thoracic Surgery of the Esophagus

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 have shown that minimally invasive staging of esophageal cancer patients is superior to conventional staging by computed tomography (CT) and endoscopic ultrasound (EUS)12 and may allow for a better selection of patients to receive combined modality therapy. In this chapter, we review our experience with minimally invasive surgery for esophageal cancer, as well as detail surgical techniques for several other diseases of the thoracic esophagus, such as resection of benign esophageal tumors and thoracoscopic treatment of esophageal dysmotility. Laparoscopic approaches to other complex esophageal operations, including achalasia and paraesophageal hernia, are covered in Chapters 14 and 15.

The optimal management of patients with potentially resectable esophageal cancer is still evolving. Although surgery remains the standard of care for early disease, several studies have suggested that definitive chemoradiation may be an acceptable alternative. This position is supported by the results of a randomized, prospective trial conducted by the Radiation Therapy Oncology Group (RTOG 8501), which compared definitive chemoradiation versus radiation therapy alone for patients with locally advanced esophageal cancer, who were not considered surgical candidates.13 The study was closed after accrual of 121 patients, due to a clear survival benefit in the combined treatment group. The surprising finding in this study was that the 5-year survival in the chemoradiation group was 27%, a rate not appreciably different from the survival rates following esophagectomy alone.14

Additional support for the use of chemoradiation for esophageal cancer comes from the results of two, large prospective European studies. In these studies, chemoradiation followed by surgery was compared to chemoradiation alone.15,16 In both studies, overall survival was equivalent between the two treatment arms. Chemoradiation with surgery decreased locoregional recurrence within 2 years of surgery. However, with chemoradiation alone, treatment-related mortality was decreased and hospital stays were shorter.15,16

These reports have led some clinicians to recommend nonoperative therapy for marginal surgical candidates, such as the elderly or those with multiple comorbidities. Indeed, the National Comprehensive Cancer Network now considers definitive chemoradiation to be an acceptable alternative to esophagectomy in their recent guidelines.17 It is incumbent upon esophageal surgeons, therefore, to continue to refine the technique of esophagectomy, in order to offer therapy with either lower morbidity, improved survival, or both compared to traditional esophagectomy and other approaches.

Staging for Esophageal Cancer

Unlike lung cancer, in which mediastinoscopy is an accepted and proven staging technique, no invasive modality is considered standard for staging patients with esophageal cancer. However, to date none of the noninvasive staging techniques currently available, such as CT, EUS, or positron emission tomography (PET), has proven accurate enough to preclude the need for invasive staging. A recent evidence-based review concluded that there exists a benefit for laparoscopic staging of esophageal cancer based on level 2 evidence, showing a sensitivity of 71 and 78% for detection of peritoneal and nodal metastasis, respectively.18 This compared favorably and exceeded sensitivities for endoscopic ultrasound and CT imaging.

The current noninvasive technology suffers from several, well-described limitations. CT, often the initial staging test performed for patients with esophageal cancer, is an appropriate tool to screen for distant disease, such as pulmonary or liver metastases. However, even in this role, occult metastatic disease is missed by CT scans in up to 15–20% of patients.19 Furthermore, CT is clearly unable to provide sufficient anatomic detail to either accurately stage the depth of invasion of the esophageal wall or determine the presence of local nodal involvement. Indeed, the accuracy of CT scanning for nodal disease is only 45–60% in most series.20,21

PET scanning is a recently introduced technology that is based on imaging the differential uptake of radio-labeled glucose by malignant and normal cells. PET scanning has been extensively studied in the context of both lung and esophageal cancer. Indeed in some centers, PET scanning has become a routine component of the preoperative evaluation of lung cancer patients. This practice is justified by several meta-analyses that have demonstrated the superiority of PET over CT in staging nodal disease in the mediastinum.22,23 However, equal efficacy for PET scanning has not been demonstrated for esophageal cancer patients. We have found the accuracy of PET scanning to assess locoregional lymph nodes in patients with esophageal cancer to be only about 50%.24 The specificity is improved, compared to CT, but the sensitivity remains poor. In our experience PET scanning has been more useful in detecting distant metastatic disease. In a series of 100 consecutive patients with potentially resectable esophageal cancer staged at our institution by PET and CT, PET identified metastatic disease in 16% of patients missed by CT.25 The false-negative rate for PET in this series was only 10% and usually occurred in cases of subcentimeter disease that was below the detection threshold of PET scans.

Another staging tool available in specialized centers is EUS. Although EUS is operator dependent, in experienced hands its accuracy for assessing T stage is greater than 90%, and it has an image resolution of 0.2 mm.26 The accuracy of determining T stage increases with penetration of the esophageal wall: the accuracy for T1 tumors is 80%, T2 tumors 90%, and T3/4 tumors 95%.27 However, the accuracy of EUS to determine nodal status is far lower than its ability to determine tumor depth and has been reported to be 65–86%.12,28

Technique of Minimally Invasive Surgical Staging

Currently, all patients at the University of Pittsburgh with a diagnosis of esophageal cancer undergo noninvasive staging with CT scans, PET scanning, and EUS. If any of these studies indicates metastatic disease or nodal involvement (in the case of EUS), a needle biopsy is performed. If distant metastatic disease is proven, palliative options are generally pursued. For patients without proven metastatic disease and GE junction tumors, we then, generally, proceed to laparoscopic staging. Laparoscopic staging is performed with the patient in a steep reverse Trendelenburg position with the surgeon standing on the patient's right side.

Operative Steps of Minimally Invasive Staging—Laparoscopy

1. An initial 10-mm blunt trocar is placed via an open, cut-down technique in the right epigastrium. The location of this port is approximately 3 cm to the right of the junction between the lower and middle third of a line connecting the xiphoid and umbilicus. After the first port is placed, a visual assessment is made of the liver and peritoneal surfaces, and, if obvious metastatic disease is present, biopsy confirmation is obtained and the staging is complete. If no metastatic disease is seen on this initial survey, a more thorough staging is performed with placement of additional port sites. These are placed in the same locations utilized for MIE.

2. The five ports generally include one 10-mm blunt cut-down port just to the patient's right of midline, midway between the xiphoid and umbilicus (for the surgeon's right hand instruments), one 10-mm port at the same level to the left of midline for the laparoscope, two additional 5-mm ports along the right costal margin (for liver retraction and dissection), and one 5-mm port on the left costal margin for countertraction by the assistant (Fig. 19-1). The liver surfaces are carefully examined and any abnormalities biopsied. Ultrasound examination of the liver may then be performed, although in our experience, the yield of ultrasound examination in patients who do not have some visual evidence of liver metastases is low.19

3. The stomach is carefully assessed for gastric extension of the tumor to determine the suitability of the stomach for gastric pull-up.

4. Nodal assessment is initiated by incising the gastrohepatic ligament. The lesser sac is entered, and nodes along the lesser curve and at the base of the celiac artery are sampled.

5. We have been evaluating preoperative “conditioning” of the esophagus. This may be performed at the time of laparoscopic staging and includes lymph node dissection of the left gastric artery and vein and division with an Autosuture Endo GIA stapler (Covidien, Mansfield, MA) with a vascular load. We also divide the short gastric vessels from the left crus to the right gastroepiploic arcade.

6. At the conclusion of the staging procedure, a laparoscopic feeding tube may be placed. However, we have found that, in most cases, dysphagia will respond to chemotherapy, rendering a feeding tube unnecessary. If chemotherapy is planned, an Infusaport is placed at the time of staging.

If the patient has no metastatic disease and minimal or no nodal disease is apparent on laparoscopy, we proceed to MIE. We have not found routine thoracoscopic staging to be very beneficial for most adenocarcinomas of the distal esophagus. Thoracoscopy is used selectively for tumors of the midthoracic esophagus, once laparoscopic staging has excluded gross intra-abdominal disease. This practice is based on our prospective series of 53 patients all of whom underwent both laparoscopic and thoracoscopic staging. Of the 36 patients with adenocarcinoma of the GE junction, those who were identified as node-positive using minimally invasive staging, 31 were identified by laparoscopy.12 If thoracoscopy is indicated, the approach is normally through the right chest, although a left-sided approach may be appropriate if suspicious pulmonary lesions are identified on that side.

Operative Steps of Minimally Invasive Staging—Thoracoscopy

1. Five ports are used for access and placed as depicted in Fig. 19-2.

2. The initial step is to mobilize the inferior pulmonary ligament and to sample the level 9 nodes.

3. Next, the pleura overlying the lower third of the esophagus is opened. Once this plane is developed, nodes from the periesophageal (level 8) and subcarinal stations (level 7) may be harvested. Lymph node dissection is continued until a positive node is found or an adequate sampling indicates benign nodes only.

Two large, prospective studies have investigated the benefits of minimally invasive staging for esophageal cancer. The first, from our institution, showed significant advantages for minimally invasive staging compared with more standard modalities.12 All 53 patients in this report underwent CT and concurrent laparoscopy and thoracoscopy. Forty-seven patients also underwent endoscopic ultrasound. The sensitivities of CT and EUS to document nodal metastases were only 33 and 63%, respectively. Even when these two modalities were combined, inaccuracies in staging were seen in 32% of cases, compared with minimally invasive staging. Only two complications were seen in this series: a prolonged air leak and a port site hernia that was repaired on the first postoperative day.

The second study, comprising 134 patients, was a multi-institution, National Cancer Institute (NCI)–sponsored study designed to determine the feasibility of minimally invasive staging.29 Successful minimally invasive staging was defined as documentation of T4 or M1 disease, the procurement of at least one abdominal and three thoracic lymph nodes, or one node that documented metastatic disease. Minimally invasive staging was successful in 73% of patients and was performed with no mortality and only minimal morbidity. Noninvasive tests, such as CT and EUS, failed to identify positive lymph nodes documented by minimally invasive staging in 20% of patients. Unfortunately, the true sensitivity of minimally invasive staging was not determined by this study because the majority of patients underwent induction chemotherapy prior to resection.

Ultimately the role of minimally invasive staging should be clarified by clinical trials that demonstrate a survival advantage for patients with node-positive disease who receive induction therapy. To date, most randomized trials have had significant limitations and demonstrated marginal benefits for preoperative chemoradiation.30 However, the poor survival obtained after surgery alone ensures that the neoadjuvant approach will continue to be investigated. We believe that a significant limitation of the studies performed to date is that patients have not been accurately staged prior to undergoing combined modality therapy. Accurate staging may identify a subpopulation of patients who would benefit from such aggressive treatment, and studies not designed for subgroup analysis may report false-negative conclusions.

Molecular Staging of Esophageal Cancer

It is estimated that between 30 and 50% of patients who are staged as node-negative by routine histological evaluation following esophagectomy will develop a recurrence of their disease.31 This suggests that these patients harbored micrometastatic disease that was undetected by routine histology. In an attempt to improve the staging of these patients, we have used minimally invasive staging to obtain lymph nodes that are evaluated with molecular biology techniques, such as reverse transcription polymerase chain reaction (RT-PCR), to determine the presence of micrometastases.32 We evaluated nodes from 30 patients who were histologically staged as node-negative.33 Of these 30 patients, 11 were identified by RT-PCR as harboring micrometastatic disease. Furthermore, the quantitative expression of carcinoembryonic antigen by RT-PCR was a powerful, independent predictor of disease recurrence and death. We believe that these techniques may identify patients with early-stage disease who have a high risk of recurrence and may benefit from additional therapy.

Minimally Invasive Esophagectomy

The technique of minimally invasive esophagectomy (MIE) that has evolved as our experience with other minimally invasive foregut procedures, such as laparoscopic Heller's myotomy, repair of giant paraesophageal hernia, and staging for esophageal cancer, has grown. At present, minimally invasive techniques for esophagectomy include laparoscopic transhiatal, laparoscopic-thoracoscopic three-hole (McKeown), and laparoscopic-thoracoscopic (Ivor Lewis) esophagectomy. Each of these can be performed with lymph node sampling or a more complete lymph node dissection. While the choice between approaches is to a large degree based on surgeon preference, the operative approach is at times dictated by anatomic location of the tumor margins.

Initial attempts at MIE were hybrid operations combining traditional open surgery with minimally invasive techniques. One of the first reports by Collard et al in 1993 included 12 patients who underwent thoracoscopic mobilization of the esophagus followed by laparotomy and preparation of the gastric conduit.9 In that series, two patients required conversion to thoracotomy for bleeding. Several subsequent reports have demonstrated the feasibility of this approach; however no definitive benefit has been shown compared to open esophagectomy.34–36

A completely laparoscopic transhiatal esophagectomy has also been described. The largest series, published by DePaula et al in 1995,37 described 48 patients who required esophagectomy predominantly for end-stage achalasia secondary to Chagas' disease. Only two patients required conversion to laparotomy. Early experience with MIE in the United States was reported in 1997, when Swanstrom and Hansen described a carefully selected group of nine patients with small tumors, benign strictures, and Barrett's disease.38 Eight of these patients had a totally laparoscopic transhiatal esophagectomy, while one required the addition of a right video-assisted thoracoscopic surgery (VATS) procedure.

Similar to these early reports, our initial efforts at MIE were with the transhiatal approach. Advantages of a totally laparoscopic approach include single patient positioning and no need for single-lung ventilation. However, we found that the disadvantages of this approach were significant. The small working space through the hiatus allowed limited access to the middle and upper third of the esophagus and made any thoracic lymph node dissection extremely difficult. Because of this, we added a right VATS to mobilize the thoracic esophagus followed by laparoscopy to prepare the gastric tube. To date, we have performed over 1000 MIEs at the University of Pittsburgh Medical Center. For the majority of our initial experience, we utilized a three-hole laparoscopic-thoracoscopic approach. In our earlier publications with this technique, we demonstrated that MIE could be performed safely with equivalent stage-specific survival as compared to the larger open series in the existing literature.11 Though technically demanding and associated with a significant operator learning curve, data from our series revealed a decrease in operative blood loss, length of stay, pulmonary complications, and narcotic requirements. In both our own experience and publications elsewhere, concerns arose regarding an increased incidence of technical complications associated with cervical esophagogastric anastomosis, including anastomotic leak, stricture, recurrent laryngeal nerve injury, and pharyngoesophageal swallowing dysfunction.39–41 In light of these concerns and the dominance of GE junction cancers in our current referral pattern, our technique has evolved to a completely laparoscopic-thoracoscopic (Ivor Lewis) esophagectomy with complete lymph node dissection. Unless contraindicated by tumor location or previous thoracic surgery, we presently favor the totally minimally invasive Ivor Lewis approach.

The main criteria favoring the Ivor Lewis approach include the following: (1) The surgical margin afforded by the Ivor Lewis approach is adequate for almost all GE junction tumors. (2) The technical experience of most training programs in thoracic and general surgery residencies is in the abdomen and chest and not in the neck. (3) The morbidity of recurrent laryngeal nerve injury is as high as 20–30% with neck anastomosis. (4) The length of gastric conduit needed to reach the neck may be up to 10 cm longer than that needed for an intrathoracic esophagogastric anastomosis. (5) Although easier management of leaks through the neck incision may be considered an advantage of cervical anastomoses, leaks from the neck may still drain into the chest after laparoscopic-thoracoscopic three-hole (McKeown) techniques especially when a narrow gastric conduit is constructed.

Early in our experience, MIE was only offered to patients with Barrett's disease and early-stage tumors; however, we now offer MIE to patients with more advanced disease. Patients found to have bulky celiac nodal metastases by CT or staging laparoscopy are not felt to be immediate candidates for MIE, and consideration is given to an open operation, a neoadjuvant protocol, or definitive chemoradiation.

Operative Technique

As previously mentioned, our preferred approach has evolved to a totally minimally invasive laparoscopic-thoracoscopic (Ivor Lewis) esophagectomy. The patient is positioned supine on the operating room table with a foot board in place. A double-lumen endotracheal tube is placed for single-lung ventilation during the thoracoscopic portion of the procedure. The laparoscopic portion of the procedure is performed first.

Laparoscopic Phase

1. The initial step of MIE is an on-table esophagogastroduodenoscopy (EGD) to confirm the precise location of the tumor, evaluate proximal and distal extent with careful attention to involvement of the cardia, and assess the suitability of the stomach as a conduit for reconstruction. It is important to minimize insufflation during the endoscopy as overdistention of the small bowel can complicate the laparoscopic phase of the procedure.

2. The laparoscopic portion of the procedure is then initiated. The surgeon stands on the right side and the assistant on the left. Five ports (three of 5 mm and two of 10 mm) are placed, similar to the staging procedure (see Fig. 19-1). Initially, we place the 10-mm port via a cut-down technique approximately 3 cm to the right of the junction between the lower and middle third of a line connecting the xiphoid and umbilicus. Carbon dioxide insufflation is utilized for pneumoperitoneum to a pressure of 15 mm Hg. The remaining ports are then placed: 5 cm to the left of the operating port (30-degree camera port), subcostal on the right and left midclavicular lines (tissue grasper ports), and in the right flank (liver retractor port). If clinically indicated, we then perform laparoscopic staging as described previously. This lower position of the ports may make the hiatal dissection somewhat difficult but greatly facilitates the mobilization of the gastric tube. This emphasizes the importance of completely mobilizing the esophagus and any hiatal hernia sac circumferentially during the thoracoscopic dissection.

3. The gastrohepatic ligament (lesser omentum) is first divided and the right and left crura of the diaphragm are dissected to mobilize the lateral wall of the esophagus (Fig. 19-3). Care is taken not to divide the phrenoesophageal membrane at this point so as to prevent loss of pneumoperitoneum into the chest cavity. The left gastric artery/vein pedicle is identified, and by tracing its course proximally the celiac lymph nodes are then examined. A complete lymph node dissection is carried out to include the celiac nodes, sweeping all nodal and fatty tissue with the specimen; the nodal dissection is later continued along the splenic artery and the superior border of the pancreas during gastric mobilization. This plane continues cephalad toward the right and left crus, continuous with the preaortic dissection plane into the lower thoracic cavity. All lymph nodes are removed, and any lymph nodes suspicious for metastatic involvement are dissected and sent for frozen-section analysis.

4. Gastric mobilization (Fig. 19-4). The dissection is then carried anteriorly and superiorly over the esophagus to finally expose the anterior hiatus. As the dissection is continued toward the left crus, the fundus of the stomach begins to be mobilized. The medial border of the right crus is dissected inferiorly until the decussation of the right and left crural fibers, thereby exposing a retroesophageal window and completing the mobilization of the superior portion of the lesser curvature and GE junction. The greater curvature of the stomach is then mobilized by first dividing the short gastric vessels, followed by division of the gastrocolic omentum while carefully preserving the right gastroepiploic arcade (see Fig. 19-4). We utilize either the ultrasonic shears such as Autosonix (Covidien, Mansfield, MA) or the LigaSure device (Valleylab, Boulder, CO). Occasionally, clips will be required during division of large-diameter, short gastric vessels. Recently, on the basis of published data42 and personal communication (Dr Earl Wilkins), we have selectively utilized an omental pedicle wrap of the intrathoracic esophagogastric anastomosis. At this point in the operation, we mobilize a long, narrow tongue of omentum from the middle to upper third of the greater curvature. We attempt to base this omental pedicle off of two feeding vessels to ensure viability (Fig. 19-5). After the gastrocolic omentum is identified, the antrum of the stomach is retracted and a window is created in the greater omentum, thus allowing access to the lesser sac. Dissection is carried along the greater curve of the stomach until the end of the gastroepiploic arcade is reached. During this mobilization, it is important to be constantly mindful of the location of the right gastroepiploic vessel.

5. The mobilized stomach is retracted superiorly, and any remaining adhesions between the posterior wall of the stomach and the pancreas are divided as well. The left gastric vessels are then identified, dissected, and divided with a vascular load of the stapler. This is done by approaching the pedicle from the lesser curve. Prior to division, a complete celiac lymph node dissection is performed, continuing along the superior border of the splenic artery and pancreas toward the splenic hilum. Adherence to oncologic principles is important at this step, so the pedicle should be dissected completely clean with all celiac and left gastric nodes swept up into the specimen.

6. Attention is then turned to mobilization of the pyloric antral area and subsequent pyloroplasty (Fig. 19-6). There are often significant adhesions in the retroantral and periduodenal regions that also need to be dissected to allow for adequate mobilization of the inferior portion of the stomach. Particular attention to mobilization of the pyloric antral area is needed in patients who have had prior cholecystectomy. Adequate mobilization is evident when the pylorus can be gently lifted up to the level of the right crus in a tension-free manner. This may require a partial or complete Kocher maneuver. Two traction sutures are placed at the edges of the pylorus with the 2-0 Endo Stitch (US Surgical, Norwalk, CT). The pyloroplasty is performed by incising the pylorus longitudinally with the ultrasonic shears and closing it transversely with interrupted sutures using the Endo Stitch device in a Heineke-Mikulicz fashion. This usually requires four to five sutures. Prior to completing the abdominal portion of the procedure, a tongue of omentum is mobilized to fashion an omental patch that is sutured to the pyloroplasty site.

7. Creation of the gastric tube. All tubes previously in the stomach or esophagus are pulled back. A 4- to 5-cm-diameter gastric conduit is then constructed using multiple fires of the stapler (4.8 mm) beginning from the lesser curve antral area, just proximal to the pylorus and heading toward the angle of His (Figs. 19-7 and 19-8). It is essential to avoid excessive manipulation and resulting trauma to the gastric conduit during all steps. To facilitate exposure, staple alignment, and conduit length during this step, we have found it helpful to have the assistant gently lift the greater curve of the stomach, along the line of the proximal short gastric arteries and retract gently toward the spleen. Simultaneously, another assistant grasps the antrum and retracts inferiorly. This is accomplished through an additional 12-mm port placed in the right lower quadrant to assist with the creation of the gastric tube. This essentially elongates the entire stomach and provides the alignment necessary to construct a consistent diameter gastric conduit without spiraling. The first stapler used for this is a vascular load to control bleeding from the adipose tissue and vessels along the lesser curve. The stapler is placed just up to, but not onto, the gastric antrum as this tends to be thicker tissue. The initial 12-mm right midclavicular port is changed to a 15-mm port to allow for the placement of a 4.8-mm Endo GIA stapler. Creation of the gastric tube is then started by dividing the stomach at the lower end of the lesser curve near the incisura using a vascular load (2.5-mm) stapler, with care being taken to preserve the main right gastric vessels and one or two of the first branches entering the antral area. The stomach is first divided across the antrum with 4.8-mm staple loads. Because this region of the stomach is generally quite thick and muscular, larger staples are required to secure its closure. Early in our experience, we discovered that very narrow gastric conduits (2–3 cm in diameter) were associated with increased gastric tip necrosis and anastomotic leaks, and therefore we now construct wider conduits measuring about 4–5 cm in diameter. Once the thicker antrum has been divided, the operating port is changed back to an 11-mm port and the fundus is divided using a 3.5-mm stapler. As the fundus is divided, the graspers are readjusted to keep the stomach constantly stretched. If there is extension of tumor onto the gastric cardia, a wider margin is left in this region.

8. Feeding jejunostomy. Under direct vision, a jejunostomy catheter (10F) is then placed using the Seldinger technique as depicted in Fig. 19-9. The patient is placed in the Trendelenburg position with the transverse colon and greater omentum retracted cranially. The 12-mm, previously placed, right lower quadrant port is used as the operating port while the right upper quadrant epigastric port is used for the camera to facilitate this maneuver. The ligament of Treitz is identified, and approximately 30 cm distal to this point, a suitable limb of proximal jejunum is tacked to the lateral, anterior abdominal wall in the left midquadrant with a single 2-0 Endo Stitch. Under direct visualization, a jejunostomy catheter (Compat Biosystems, Minneapolis, MN) is then placed, with intraluminal position confirmed by distending the jejunum with 10 mL of air insufflated via the catheter. The jejunum is then securely tacked to the abdominal wall at the catheter entry site with a purse-string type circumferential tacking stitch using a 2-0 Surgidac Endo Stitch. A second simple 2-0 Surgidac Endo Stitch is placed 3 cm distal to the catheter insertion site so as to prevent torsion and possible strangulation around a single fixed point (see Fig. 19-9).

9. The tip of the gastric conduit is then secured to the specimen with 2-0 Endo Stitch (Fig 19-10). During this step, care is taken to maintain alignment so that subsequent retrieval of the specimen through the hiatus into the chest does not lead to any rotation and maintains perfect anatomic alignment of the gastric conduit with the short gastrics facing the direction of the spleen and the lesser curve staple line facing the right chest. With our recent use of omental pedicles, we have also started tacking the omental pedicle wrap to the proximal end of the conduit so as to facilitate bringing it through the hiatus without trauma to the omentum or the supplying vasculature.

10. If the hiatus appears wide, we add one or two 0 Surgidac sutures (Covidien, Mansfield, MA) to approximate the right and left crus to minimize the likelihood of a delayed herniation of the conduit into the chest. The pyloroplasty site is covered with an omental patch as described previously. The initial Hasson trocar site is closed with the Carter-Thompson suture passer with 0 Vicryl suture, the abdomen is desufflated, and the skin incisions are closed accordingly.

Thoracoscopic Phase

1. The patient is placed in the left lateral decubitus position. The operating surgeon stands on the right side of the table (facing the patient's back) and the assistant on the left side of the table.

2. Five thoracoscopic ports are used (see Fig. 19-2; Fig. 19-11). A 10-mm camera port is placed in the seventh or eighth intercostal space, just anterior to the midaxillary line. The surgeon's working port is a 10-mm port that is placed at the eighth or ninth intercostal space, posterior to the posterior axillary line. Ultimately, this eighth posterior interspace port will be enlarged to 5 cm to enable passage of the end-to-end stapler (EEA, US Surgical, Norwalk, CT) and removal of the specimen. Another 10-mm port is placed in the anterior axillary line at the fourth intercostal space, through which a fan-shaped retractor aids in retracting the lung to expose the esophagus. A 5-mm port is placed just inferior to the tip of the scapula, and this is used by the surgeon's left hand for countertraction. A final port is placed at the sixth rib, at the anterior axillary line for suction, and is especially useful while fashioning the anastomosis.

3. An important initial step to aid in exposure is placement of a traction suture (0-Silk) through the central tendon of the diaphragm (Fig. 19-12), which is brought out through a 2-mm stab incision in the antero-lateral chest wall near the costophrenic angle using an Endo Close device (Covidien, Mansfield, MA). This suture retracts the diaphragm inferiorly and allows excellent visualization of the lower one-third of the esophagus.

4. Thoracic esophageal mobilization (see Fig. 19-12). Mobilization of the esophagus is begun by dividing the inferior pulmonary ligament to the level of the inferior pulmonary vein and retracting the lung anterior. This facilitates incision of the mediastinal pleura over the esophagus. Dissection moves in a cranial direction from this point along the line of the mediastinal pleura. It should be noted that the dissection should be carried down to the pericardium as it is actually the medial boundary of the line of dissection. The deep boundary is the contralateral pleura. The esophagus and accompanying periesophageal tissue and level 7 lymph nodes are mobilized circumferentially en bloc toward the right mainstem bronchus and carina. Care is taken not to injure the posterior membranous wall of the right mainstem bronchus in this area. We use the ultrasonic shears for much of the dissection, as the sharp blade of this instrument is ideal for a precise dissection plane. Endoscopic clips are utilized for hemostasis on larger vessels. Because of the extensive lymphatics in this area and fragile vessels attached to the subcarinal nodes, careful use of endoclips also aids in minimizing oozing of chyle and blood. Lateral dissection is facilitated by opening the mediastinal pleura in the groove posterior to the esophagus. This should be done in a superficial dissection plane so as to avoid injury to the aorta and the thoracic duct. The azygous vein is mobilized and divided as it overlies the esophagus posteriorly with a vascular staple load. The vagus nerve is transected above the level of the divided azygous vein to prevent any traction injuries to the recurrent nerve during the mobilization of the esophagus. The esophagus is then mobilized circumferentially from the hiatus to near the thoracic inlet, the ultimate cephalad extent depending on the proximal extent of the tumor and/or Barrett's esophagus and the length and condition of the gastric conduit. Above the azygous vein, the plane of dissection should stay directly on the esophagus so as to prevent injury to the posterior membranous trachea and recurrent laryngeal nerve. We do not perform an aggressive lymph node dissection at level 2 or level 4 unless preoperative PET, CT, or EUS confirmed presence of malignant nodes at this level.

5. The distal esophagus and previously constructed gastric conduit are then brought up through the hiatus into the chest (Fig. 19-13). Maintaining proper orientation of the gastric conduit is critical to avoid spiraling or twisting of the conduit. The staple line should face the camera so as to avoid spiraling of the conduit. The stitch is cut between the specimen and the conduit, and the specimen are retracted anteriorly and superiorly. We carefully estimate the amount of conduit that will lie in the chest. It is a common mistake to bring an excess amount of stomach into the chest in an effort to minimize tension on the anastomosis. This excess conduit will often assume a sigmoid conformation above the diaphragm and may lead to significant problems with gastric emptying.

6. The proximal esophagus is then transected above the azygous vein with Endo Shears (Covidien, Mansfield, MA). Again, the precise location of this division and ultimate location of the anastomosis tends to be high, near the thoracic inlet. However, cutting the esophagus too proximal may make the anastomosis technically difficult and should be avoided. In the case of concern over tumor margin, we may rescope at this point to precisely determine where to transect the esophagus.

7. The eighth interspace port site is enlarged, and an Alexis wound protector (Applied Medical, Rancho Santa Margarita, CA) is placed for specimen removal after cutting the previously placed sutures that secured the conduit to the specimen. The specimen is then sent for frozen-section analysis of the esophageal and gastric margins.

8. Creation of intrathoracic esophagogastric anastomosis (Figs. 19-14 and 19-15). The anvil of a 28-mm EEA stapler is placed in the proximal esophagus, and a 2-0 Endo Stitch purse-string suture is placed and tied (intracorporeal technique) to secure the anvil in position. It is technically challenging to make this first stitch perfect as the anvil has a tendency to migrate out of the open end of the proximal esophagus. For this reason, a second purse-string suture is placed to further secure the anvil and pull in any mucosal defects, thereby ensuring complete rings following EEA firing. Ultrasonic shears are used to open up the tip of the gastric conduit along the staple line. The EEA stapler is then introduced through the eighth interspace incision into the tip of the gastric conduit via the gastrotomy at the apex of the conduit. This is technically challenging for most trainees, and care must be taken to angle the gastric tube facing straight up to accept the tip of the EEA device aimed straight down, much the same way one angles the tip of your foot as you pull on your sock. The anvil is then docked into the stapler. A circular anastomosis is then created in an end- (proximal esophagus) to-side (gastric conduit) fashion above the level of the azygous vein. A reticulating Endo GIA stapler is used to close the gastrotomy closure and excise the redundant portion of the gastric conduit tip. Routine endoscopy is not performed.

9. As previously mentioned, we have recently starting selectively wrapping a tongue of omentum mobilized from the greater curve of the stomach around the anastomosis, securing in place with 2-0 Surgidac Endo Stitch at several points (Fig. 19-16). It is important to ensure that the conduit is not twisted in the process of wrapping the omentum around the anastomosis.

10. Under direct vision, a nasogastric tube is advanced beyond the anastomosis to just above the hiatus. The chest is drained with a 28F chest tube placed posteriorly but not on the anastomosis, and a number 10 Jackson Pratt drain placed directly posterior to the anastomosis, behind the gastric conduit, down to the diaphragmatic hiatus, across the dome of the diaphragm, and out through a small stab incision near the costophrenic angle. To prevent herniation, the conduit is tacked to the right crus with one or two interrupted 2-0 Endo Stitches.

Outcomes and Complications Following Mie

In 2003, we published our series of 222 consecutive patients who had undergone McKeown or “three-hole” (laparoscopic-thoracoscopic with cervical anastomosis) MIE at the University of Pittsburgh.11 To this date, the approximately half of our MIEs (>500 cases) was performed with this three-field technique. Indeed, the procedure was the mainstay of our initial experience in the first 10 years with reduced perioperative morbidity and mortality compared with many other open series. Although early in the series we selectively performed MIE on patients with smaller tumors and no previous therapy, 35% of the patients in the overall series had been treated with chemotherapy and 16% with radiation. In addition, 25% of patients had undergone prior open abdominal surgery.

MIE was completed as planned in 206 patients (93%). There were no emergent conversions to an open procedure. Of the 16 cases who required nonemergent conversion, 11 required a minithoracotomy for adhesions and, in one case, oversewing of an intercostal vessel that could not be controlled by VATS.

There were three deaths in the series (mortality 1.4%). These deaths were from postoperative pneumonia and multisystem organ failure in one patient, a myocardial infarction on postoperative day 5 in another, and pericardial tamponade that developed 3 days after MIE in the third patient. None of these deaths were in patients who developed an anastomotic leak or gastric tube necrosis. Presumably, traction injury to the pericardium during VATS was the mechanism for the development of postoperative tamponade in the third patient.43 This very low mortality rate compares favorably with the largest series of open esophagectomy (Table 19-1).

The rate of anastomotic leak in this series was 11.7%. In our experience, this complication was frequently related to the diameter of the gastric tube. The leak rate associated with a 3-cm-diameter tube was 26% in 56 consecutive patients. In the latter half of the series, those patients who underwent creation of a larger diameter conduit had the leak rate of only 6%. Thus, there is invariably an operator learning curve.

Injury to the recurrent laryngeal nerve is a complication associated with significant morbidity. Mechanisms related to this complication include excessive traction on the nerve during the neck dissection or injury during dissection of the upper one-third of the esophagus. In our series, vocal cord palsy occurred in 3.6% of patients. This is lower than our open experience and is in part due to enhanced visualization of the upper thoracic esophagus during VATS. We believe early division of the vagus nerve and limiting lymph node dissection above the azygous vein are important technical details that contribute to lower rates of injury to the nerve in this area. However, as previously mentioned, in addition to recurrent nerve injury, a significant number of patients experience pharyngoesophageal swallowing dysfunction after cervical anastomosis. These are among the concerns that prompted our recent switch to a totally minimally invasive Ivor Lewis approach in the last several years.

Other complications seen after MIE, as well as open esophagectomy, include chylothorax, delayed gastric emptying, and airway injuries. All of these complications are potentially related to surgical technique. Inadequate control of small ductules that branch off of the thoracic duct or a gross tear of the main duct is typically the cause of a chylothorax. Seven patients (3%) developed this complication early in our series. Following this early experience, we have liberally applied clips to even small branches emanating from the thoracic duct along the right esophageal border during VATS, and this complication has fallen to less than 1%. Delayed gastric emptying is reported to occur in up to 10% of patients following esophagectomy. This may be due to a number of factors, including the vagotomy itself, the creation of a full-size gastric conduit that may empty poorly compared to a tubularized conduit, incomplete pyloromyotomy or pyloroplasty, spiraling of the gastric tube, excess stomach above the diaphragm leading to a sigmoid loop effect, and an inadequate crural opening. In our series, only 2% of patients developed delayed gastric emptying after MIE. The creation of a pyloroplasty rather than a pyloromyotomy and attention to all of the details listed previously have contributed to this low complication rate.

Fortunately, significant airway injuries in our experience have been exceedingly rare, occurring in only two patients. One of these injuries occurred postoperatively during reintubation for respiratory distress and one was believed to result from injury to the posterior membranous trachea from unintentional contact of the autosonic shears. In other series, tracheal injury has been associated with the resection of bulky, midthoracic tumors. This is usually either due to traction or cautery injury during esophageal mobilization. In these cases of bulky tumors, we would therefore recommend a thoracotomy, particularly if the patient has received neoadjuvant radiation.

With a median follow-up of 19 months, overall survival was similar to that after open esophagectomy. Of importance in assessing outcomes is not only overall survival but also the quality of life following esophagectomy. We have documented this by administering a validated quality-of-life instrument (Short Form-36 [SF-36]) and a disease-specific questionnaire (the Gastroesophageal Reflux Disease Health-Related Quality of Life [GERD-HR-QOL] index44) to patients before and after MIE. The GERD-HR-QOL instrument noted that dysphagia and heartburn scores following esophagectomy were excellent, and that only 4% of patients had severe, poorly controlled reflux. In addition, the overall quality of life as measured by the SF-36 was no different than that of age-matched controls.

In our experience, perhaps the most significant technical concern with the minimally invasive McKeown approach is the cervical dissection. Recurrent laryngeal nerve injuries, perturbations in pharyngeal transit, and swallowing dysfunction even in the absence of recurrent nerve injury are not infrequent. Moreover, as described in open series using a cervical anastomosis, anastomotic stricture and leak have been shown to occur with increased frequency.45 Out of these concerns emerged our more recent experience with completely thoracoscopic-laparoscopic Ivor Lewis esophagectomy. However, we did first evolve through a transition phase whereby a minithoracotomy (hybrid approach) was performed for creation of the intrathoracic anastomosis.

Outside of case reports, there are currently few series reporting experience with laparoscopic-thoracoscopic Ivor Lewis esophagectomy.46,47 Kunisaki et al described a small series of laparoscopic-thoracoscopic Ivor Lewis esophagectomies (n = 15), but the anastomotic leak rate was somewhat high (13.3%) and length of stay was prolonged (30 days).48 We recently reported the largest series of minimally invasive Ivor Lewis esophagectomies (n = 50) published to date.49 Of these, the first 35 included hybrid approach with a planned minithoracotomy. The last 15 patients in this series were performed with a completely laparoscopic-thoracoscopic method without need for minithoracotomy. The median length of stay was 9 days for the entire group, with the completely minimally invasive group having a significantly shorter hospitalization (7 vs 9 days). The median ICU stay was 1 day for both groups. The anastomotic leak rate was 6%. All pneumonias (10%) occurred in the hybrid minithoracotomy group. Importantly, there were no recurrent nerve injuries.

We believe that the experience with totally thoracoscopic-laparoscopic Ivor Lewis esophagectomy will ultimately reproduce the low morbidity and mortality we have previously published with our established MIE technique. The omission of a cervical dissection has reduced our recurrent nerve injury rate to near zero. From a theoretical standpoint, one would presume that pharyngeal transit problems and oropharyngeal swallowing dysfunction should be reduced as well with a chest anastomosis. It should be emphasized that there is a steep operator learning curve associated with this approach. Both blood and lung can obscure visualization of the esophagus, which lies at the dependent aspect of the operative field. Prone positioning has been described as an alternative approach that may facilitate operative exposure and address such technical concerns.50

Benign Esophageal Disease

Resection of Esophageal Leiomyoma

Leiomyomas represent the most common benign tumor of the esophagus, accounting for approximately two-thirds of all cases.51 These tumors occur in the middle (33%) and lower (56%) esophagus, a distribution that parallels the degree of smooth muscle in the esophageal wall.51 Consequently, leiomyoma are rarely found in the cervical esophagus, which is composed predominantly of skeletal muscle. The majority of these tumors arise from the muscularis propria and extend into the lumen of the esophagus. On occasion, however, they may arise from the muscularis mucosa, in which case they tend to pedunculate because of peristalsis.52

Over 85% of patients with small leiomyoma are asymptomatic. When present, symptoms are often nonspecific, such as chest pain, regurgitation, and dysphagia. On rare occasion, these tumors may ulcerate and present with gastrointestinal bleeding. Interestingly, there does not appear to be a clear correlation between the size of the tumor and either the frequency or severity of symptoms.53,54

The natural history of these uncommon tumors is not well understood, and therefore the guidelines for resection of asymptomatic tumors are unclear. Certainly, resection of either symptomatic tumors or those in which a malignant histology is suspected is appropriate. In most series, the criterion for resection of asymptomatic lesions has been a size greater than 3–5 cm. However, it has been well-documented that the size of these tumors can remain stable over several years.55 Furthermore, unlike smooth muscle tumors of the stomach, the propensity of these tumors to degenerate into leiomyosarcoma is extremely rare, and in fact only two cases have ever been documented.56,57 What is clear is that the decision to recommend surgery will depend on the morbidity associated with the procedure.

Technique of Resection

The approach to resection depends on the location of the tumor. Including our own experience, in most published series, benign esophageal tumors (ie, leiomyoma) of the thoracic esophagus are approached through a right VATS or right thoracotomy, whereas a laparoscopic transhiatal approach is employed for most distal tumors at or near the GE junction.58–60 Although there are published case series that report resection of GE junction leiomyoma with left-sided thoracoscopy,61 we are not in favor of this approach. Similarly, although a distal intrathoracic, benign esophageal tumor could be enucleated through a laparoscopic transhiatal approach, we believe the best exposure is achieved through the right chest. Our preference is to resect tumors through a minimally invasive approach, reserving thoracotomy or laparotomy for tumors larger than 7 cm. For the purposes of this chapter, we focus on the right VATS approach.

1. The patient is intubated with a double-lumen endotracheal tube for single-lung ventilation.

2. Esophagoscopy is performed prior to draping to confirm location of the tumor. The scope is frequently left in place to assist the surgeon in determining where to begin the myotomy. In some cases, a 54F bougie may be left in place to facilitate dissection and accentuate tumor location.

3. The patient is positioned in the left lateral decubitus position. The surgeon stands at the patient's back.

4. The thoracoscopic ports are essentially the same as those used for MIE as depicted in Fig. 19-2.

5. Exposure of the tumor is obtained by placing the diaphragm stitch, as previously described, above for tumors in the distal thoracic esophagus. Removal of benign midesophageal lesions does not always require this maneuver. Subsequently, the inferior pulmonary ligament is divided with the ultrasonic shears. The mediastinal pleura overlying the esophagus is opened sharply. Care must be exercised at this point to preserve the vagus nerve trunk and its branches. The esophagus may need to be dissected circumferentially for exposure, particularly if the tumor appears to arise from the left side of the esophagus. A Penrose drain can be placed around the esophagus and manipulated to help expose left-sided tumors (Fig. 19-17).

6. A myotomy is performed on the esophageal wall overlying the tumor (Fig. 19-18). The longitudinal muscular layer is then opened sharply and the leiomyoma is exposed. The vagal trunks should be identified and preserved during this maneuver. Because of the firm, rubbery nature of the tumor, it is often difficult to grasp and we frequently place a stitch into the tumor for traction. The plane between the tumor, muscularis propria, and submucosa is developed.

7. The tumor is then enucleated with the ultrasonic dissector, hook electrocautery, and the Endo Peanut (Covidien, Mansfield, MA).

8. The tumor is removed with an endoscopic specimen bag.

9. After the tumor is removed, the esophagus is submerged under water and insufflated with air from the esophagoscope to determine mucosal integrity.

10. The myotomy is then closed using interrupted 2-0 Surgidac Endo Stitch (Fig. 19-19). Although not all surgeons feel that this step is necessary,62 several studies have documented the occurrence of postoperative dysphagia due to the formation of a mucosal pseudodiverticulum at the myotomy site. In these cases, symptoms resolved after approximation of the myotomy.

Outcomes of Minimally Invasive Thoracoscopic Resection for Leiomyoma

Between 1990 and 2005, we resected 15 patients with esophageal leiomyoma.63 In this series, the tumor location was midesophageal in eight patients and distal third of the esophagus in six patients. All the patients with a tumor less than 7 cm in the thoracic esophagus were approached with a right VATS. Four patients with midesophageal tumors went on to require an additional antireflux procedure for either new-onset or worsening reflux. Among all patients, there were no perioperative complications and the median hospital stay was 2.3 days. One patient was noted to have a mucosal injury at time of surgery; this was repaired using an endo-GIA stapler over a bougie without complication. The mean tumor size was 2.7 cm; however, we have safely resected tumors up to 8 cm in size using minimally invasive techniques. Larger tumors do pose a greater technical challenge. As such, we recommend reserving thoracoscopic resection for tumors less than 7 cm. On the basis of this limited data set, the size of the tumor does not correlate with the development of postoperative reflux. Patients require close follow-up because of the potential for delayed postoperative reflux.

The introduction of minimally invasive techniques has revolutionized the treatment paradigm of patients with achalasia. The long-term benefits of surgery over medical management have been clearly documented for many years.64,65 However, in the past, patients were often not referred for surgery because of the morbidity of the thoracotomy necessary for an esophagomyotomy. The advent of minimally invasive techniques has led to a resurgence in surgery as the primary treatment modality for this disease.4

Most surgeons experienced in the treatment of achalasia have adopted laparoscopy as their preferred approach (refer to Chap. 14). Indeed in our own series of minimally invasive esophagomyotomy, 92% of patients underwent laparoscopy as opposed to thoracoscopy.66,67 Similarly, the initial group to describe VATS myotomy has now come to favor laparoscopy.68 However, there are reasons to consider thoracoscopy as an acceptable alternative. During thoracoscopy, the distal esophagus and GE junction are visualized without the necessity of dividing the phrenoesophageal ligament. Proponents of thoracoscopy claim, consequently, that the preservation of this ligament will prevent postoperative reflux and obviate the need for an antireflux procedure, which is usually added after a laparoscopic esophagomyotomy.69

However, there are some inherent disadvantages to thoracoscopic myotomy. First, anesthesia is complicated by the need for single-lung ventilation. In addition, thoracoscopy is more uncomfortable for the patient, particularly because a “minithoracotomy” access incision70,71 and a chest tube are often required for the procedure. More important is the concern that the myotomy may be incomplete when performed thoracoscopically. Critics of the operation cite the difficulty of working in a plane perpendicular to the esophagus and extending the myotomy adequately onto the stomach when working through the chest.72 Additionally, the addition of a partial fundoplication to myotomy for the treatment of achalasia has become standard practice and is readily performed and with reproducible results using laparoscopy.

Overall, thoracoscopic myotomy has been shown to provide symptomatic improvement in 76% of patients with achalasia. These results do not compare favorably to laparoscopy, in which 94% of the nearly 500 patients reported in the literature have had relief of their dysphagia.72 In addition, a 35% rate of postoperative reflux is associated with thoracoscopy, compared with a rate of only 9% following laparoscopic myotomy and fundoplication.73

Most recent reports of thoracoscopic myotomy describe a “hybrid operation,” which utilizes a minithoracotomy through which standard instruments are used.74,75 Additional port sites are placed to provide illumination and counter-retraction. This approach likely reflects the preferences of thoracic surgeons who may not be as familiar with techniques of laparoscopy. We favor laparoscopy, as do the vast majority of surgeons performing myotomy. In our opinion, only the rare patient with a hostile abdomen from multiple prior abdominal procedures would be a potential candidate for VATS myotomy. Even in this setting, a laparoscopic approach would still be considered preferable.

Other Indications

A variety of other thoracoscopic esophageal procedures have been described, though their merit is difficult to determine due to the rarity of the diseases and the small number of patients studied. Aside from esophageal tumors (benign and malignant) and achalasia, thoracoscopic management of esophageal diverticulum has also been reported in the literature. Similar to the literature on leiomyoma, many authors report utilizing a laparoscopic transhiatal approach for epiphrenic diverticula at or near the GE junction. Palanivelu et al reported one of the larger more recent experiences with a minimally invasive approach.76 In their series, eight epiphrenic (defined as within 10 cm of the GE junction) and four thoracic (“midesophageal”) diverticula were resected. Laparoscopy (with or without myotomy and fundoplication) was employed for the epiphrenic diverticula whereas prone position right-sided thoracoscopy was used for the thoracic diverticula. Myotomy was included only when an underlying motility disorder was present. The only anastomotic leak occurred with a midthoracic diverticulum resected by VATS. In a few, very small series (fewer than five patients), results were described as “excellent.”77,78 However, in a larger series of 11 patients from France, three developed an esophageal fistula and two required reoperation.79 The authors of that study concluded, “Minimally invasive surgery does not confer significant benefit compared with open surgery in the treatment of diverticula of the thoracic esophagus.” We have reviewed our experience with this disease.80 Of 20 patients who underwent minimally invasive surgery for esophageal diverticula (either laparoscopy or VATS) at UPMC, four patients developed an esophageal leak and one death occurred as a result. Overall, the results from these small case series of thoracoscopic resection of midesophageal diverticula suggest the potential for considerable morbidity with a 20–30% leak rate. Management of epiphrenic diverticula with a minimally invasive laparoscopic approach (resection with or without myotomy and fundoplication depending on underlying pathology) seems to yield better results with low morbidity.

Thoracoscopic treatment of Boerhaave's syndrome81,82 and repair of an anastomotic leak following esophagectomy83 have also been described in case reports. A minimally invasive approach certainly merits consideration in these cases only if the surgeon feels he/she can make safe and expeditious progress in these semiurgent cases. In general, we approach the majority of these cases through an open approach.