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Thoracoabdominal esophagectomy still plays a major role in the oncological treatment for esophageal cancer. Minimally invasive procedures were developed to reduce the high rate of postoperative morbidity and mortality without negatively affecting the oncological outcome.What evidence supports minimally invasive oncological surgery of the esophagus? Do patients benefit from minimally invasive esophagectomy compared to an open approach? Is the reduction of surgical access trauma specifically advantageous?Review, evaluation and critical analysis of the international literature.A reduction in postoperative morbidity by decreasing surgical trauma was confirmed by three prospective randomized clinical trials, while showing at least similar oncological outcomes. Diverse retrospective analyses and meta-analyses also came to the same result.A minimization of surgical access trauma during thoracoabdominal esophagectomy reduces postoperative morbidity compared to conventional open surgery. Recent evidence suggests that oncological outcomes are not altered depending on the surgical approach.HINTERGRUND: Die thorakoabdominale Ösophagektomie spielt bei der Therapie des Ösophaguskarzinoms weiterhin die tragende Rolle. Minimal-invasive Verfahren wurden entwickelt, um die hohe Rate an postoperativer Morbidität und Mortalität zu reduzieren, ohne das onkologische Ergebnis dabei zu gefährden.Welche Evidenz besteht in der minimal-invasiven onkologischen Chirurgie des Ösophagus? Profitieren Patienten von einer minimal-invasiven Ösophagektomie im Vergleich zur offenen Technik? Ist eine Reduktion des chirurgischen Zugangstraumas im Einzelnen von Vorteil?Die internationale Literatur wurde gesichtet, ausgewertet und kritisch analysiert.Drei prospektiv randomisierte Studien bestätigen eine Reduktion der postoperativen Morbidität durch die Reduktion des chirurgischen Zugangstraumas bei mindestens gleichwertigem onkologischem Ergebnis. Zu diesem Ergebnis kommen auch diverse retrospektive Analysen sowie Metaanalysen.Eine Minimierung des chirurgischen Zugangstraumas bei der thorakoabdominalen Ösophagektomie führt zu einer Reduktion der postoperativen Morbidität im Vergleich zur offenen Chirurgie. Das onkologische Ergebnis bleibt davon nach aktueller Datenlage unbeeinträchtigt.

Transthoracic esophagectomy is generally accepted as the standard of surgical care for patients with esophageal cancer. Despite improvements in the perioperative management this surgical procedure is associated with a clinically relevant morbidity. Fast-track protocols (synonym: enhanced recovery after surgery, ERAS) are conceived to perioperatively maintain the physiological homoeostasis and thereby to accelerate postoperative rehabilitation and reduce morbidity. In this prospective observational study the initial experiences of a high-volume center with the implementation of an ERAS protocol after transthoracic esophagectomy were analyzed.A total of 26 patients with esophageal cancer and a low index of comorbidities prior to hybrid Ivor Lewis esophagectomy were included in this study. According to an ERAS protocol all patients underwent a standardized perioperative treatment pathway aiming to discharge the patients from the inpatient treatment on postoperative day 10. The primary outcome parameter was the rate of major complications (Clavien-Dindo IIIb/IV), which was compared to a cohort of 52 non-ERAS patients.The ERAS programs with the various core elements can be implemented in patients scheduled for transthoracic esophagectomy, although the organizational and personnel expenditure of this fast-track protocol is high. The length of hospital stay appears to be reduced without compromising patient safety. The limiting variable of the ERAS protocol remains the early and adequate enteral feeding load of the gastric conduit before discharge on postoperative day 10.HINTERGRUND UND FRAGESTELLUNG: Die transthorakale Ösophagektomie ist gegenwärtig der chirurgische Standard in der Behandlung des Ösophaguskarzinoms. Dieses operative Verfahren ist trotz Verbesserungen im perioperativen Management mit einer klinisch relevanten Morbidität assoziiert. „Fast-track“-Protokolle (Synonym: „enhanced recovery after surgery“, ERAS) sind konzipiert, um perioperativ die physiologische Homöostase zu erhalten und damit die postoperative Rehabilitation zu beschleunigen. In dieser prospektiven Beobachtungsstudie werden die ersten Erfahrungen eines High-volume-Zentrums bei der Umsetzung eines ERAS-Programms nach transthorakaler Ösophagektomie analysiert.Insgesamt 26 Patienten mit Ösophaguskarzinom und geringer Komorbidität wurden vor geplanter Hybrid-Ivor-Lewis-Ösophagektomie in diese Studie eingeschlossen. Entsprechend einem ERAS-Protokoll wurde bei allen Patienten ein standardisierter perioperativer Behandlungspfad mit dem Ziel implementiert, die Patienten am 10. postoperativen Tag aus der stationären Behandlung zu entlassen. Primärer Outcomeparameter war die Rate der „major complications“ (Clavien-Dindo IIIb/IV), die mit einem Kontrollkollektiv von 52 Non-ERAS-Patienten verglichen wurden.ERAS-Programme sind mit ihren Kernelementen bei der transthorakalen Ösophagektomie umsetzbar, der organisatorische und personelle Aufwand zur Umsetzung dieses „Fast-track“-Protokolls ist hoch. Die Krankenhausverweildauer scheint mit diesem Programm verkürzt zu werden, ohne dass die Sicherheit des Patienten beeinträchtigt wird. Die limitierende Determinante ist die frühe und kalorisch ausreichende enterale Belastung des hochgezogenen Schlauchmagens bis zum Zeitpunkt der Entlassung am 10. postoperativen Tag.

In the current German S3 guidelines surgical treatment is not recommended for metastatic gastric cancer or metastatic adenocarcinoma of the esophagogastric junction; however, in routine practice the indications can be extended so that there may be occasions in which radical surgical intervention for specific individuals may be appropriate as part of a multimodal therapy with curative intent. This article presents the scientific rationale of such an approach based on the available literature considering modern, multimodal therapy concepts including criteria to be met for radical surgery. Currently only retrospective trials and limited current meta-analysis data are available for justifying surgical treatment for metastatic adenocarcinoma. The recently published initial results of the FLOT-3 study identified a patient subgroup that benefits from a resection even though metastasis has occurred. Whether surgical therapy will become an integral part of the treatment of limited metastatic adenocarcinoma of the stomach and esophagus in the future, has to be demonstrated by large prospective randomized studies, such as the RENAISSANCE/FLOT-5 study.

In the current German S3 guidelines surgical treatment is not recommended for metastatic gastric cancer or metastatic adenocarcinoma of the esophagogastric junction; however, in routine practice the indications can be extended so that there may be occasions in which radical surgical intervention for specific individuals may be appropriate as part of a multimodal therapy with curative intent. This article presents the scientific rationale of such an approach based on the available literature considering modern, multimodal therapy concepts including criteria to be met for radical surgery. Currently only retrospective trials and limited current meta-analysis data are available for justifying surgical treatment for metastatic adenocarcinoma. The recently published initial results of the FLOT-3 study identified a patient subgroup that benefits from a resection even though metastasis has occurred. Whether surgical therapy will become an integral part of the treatment of limited metastatic adenocarcinoma of the stomach and esophagus in the future, has to be demonstrated by large prospective randomized studies, such as the RENAISSANCE/FLOT-5 study.