Surgery: Minimally invasive esophagectomy

Technical advancements and development of endoscopic equipment in thoracoscopic surgery have resulted in increase in the popularity of minimally invasive esophagectomy (MIE). To date, a number of single-institution studies and several meta-analyses have demonstrated acceptable short-term outcomes of thoracoscopic esophagectomy for esophageal cancer, and the outcomes are comparable to those of conventional open esophagectomy (OE). Extended mediastinal lymphadenectomy including the upper mediastinal nodes along the bilateral recurrent laryngeal nerves (RLNs) is considered as a standard surgery for thoracic esophageal squamous cell carcinoma in Japan. Nowadays, precise upper mediastinal lymphadenectomy along the bilateral RLNs is also feasible, even with thoracoscopic approaches. However, there have been a limited number of prospective multicenter trials to verify the feasibility and benefits of MIE to date. Comparison of the left lateral decubitus position with the prone position also should be assessed as appropriate positioning for MIE, with regard to precise upper mediastinal lymphadenectomy along the bilateral RLNs for esophageal squamous cell carcinoma. Furthermore, the oncological benefit to patients undergoing MIE has not been scientifically proven because there have been no randomized controlled trials to verify the equivalency in long-term survival of patients undergoing MIE compared with that of patients undergoing OE. If future prospective studies indicate oncological benefits, MIE could truly become the standard care for patients with esophageal cancer. Although several studies have emphasized that robot-assisted thoracoscopic esophagectomy is safe and feasible, the superiority of robot-assisted thoracoscopic esophagectomy compared with conventional thoracoscopic esophagectomy should be carefully evaluated because robot-assisted thoracoscopic esophagectomy is not comparable with conventional MIE in terms of the cost of a surgery.