Comparison of the Outcomes Between Open and Minimally Invasive Esophagectomy

Esophageal resection for cancer remains the gold standard, not only in providing the optimal chance for cure but also the best palliation for dysphagia. Because of the substantial morbidity from the open surgical approach to the chest, there have been attempts to use approaches that avoid a thoracotomy. However, to date there has been no clear evidence that the avoidance of thoracotomy using a transhiatal approach to resect the esophagus improves outcomes either in relation to morbidity1,2 or survival with the disease.3 The latter randomized trial showed a trend to a benefit for the transthoracic approach thought to be due to the ability to perform a more complete lymph node dissection.3 The extent to which the lymph nodes should be dissected remains contentious.4 Promoters of the open approaches to esophageal resection strongly support a radical approach to a mediastinal lymphadenectomy, whereas the advocates of the transhiatal approach hold the view that a more extensive lymphadenectomy does not influence survival.5 With improved experience and skills for performing laparoscopic and thoracoscopic surgery, there have been a number of reports where these approaches have been used in association with the thoracic dissection of the esophagus6–8 or gastric mobilization,9,10 or for both.11,12 These reports have confirmed that these approaches are possible, safe and have reasonable outcomes when compared with the literature. Conceptually, a minimally invasive approach to esophageal resection (MIE) does appear to offer the potential for a more radical approach to mediastinal resection, under vision, when compared with transhiatal esophagectomy. Recent reviews of the role of MIE have maintained that the benefits from this approach are controversial because the operations are more complex than those required for other malignancies. There are concerns relating to the adequacy of tumor and lymph node clearance, and most series reported to date have not shown an apparent reduction in morbidity or mortality.4 Wu and Posner identified issues such as the optimal approach, cost effectiveness, advantages over open techniques and the role of MIE in combined modality therapy and call for more comparative studies to determine the worth of MIE.13 There has been very little written about the oncological impact and the impact on prognosis from the resected cancer using MIE. Our unit has been performing thoracoscopic mobilization for esophageal cancer since 1993. The results from our first 162 cases have been reported previously.13 We concluded that the procedure was safe with acceptable outcomes. We subsequently embarked upon a pilot study of a consecutive series of patients having Total MIE using thoracoscopic esophageal mobilization and laparoscopic gastric mobilization and a small right upper quadrant incision to create the gastric tube. We felt that there was little benefit over the thoracoscopic and laparotomy approach, so this operation was discontinued. We have recently reported this series with short- and medium-term follow-up data questioning whether there is a significant benefit from Total MIE.14 In both of these series of patients, the tumors were in the intrathoracic esophagus or localized in the esophagogastric junction (EGJ) allowing resection and a gastric pull-up to the neck. Prior to using MIE techniques, we had used an open approach via laparotomy and thoracotomy to resect these cancers. Concurrent with those series of patients in which MIE techniques were used, we have used the open approach for cancers located at the EGJ (Siewert Type II and III) as well as the lower esophagus, where a substantive resection of the upper stomach was required, to allow appropriate tumor clearance and necessitating an intrathoracic anastomosis. In this report, we wish to compare the outcomes from two approaches to MIE with open esophageal resection in a contemporary series of patients from a single unit. Aside from the amount of esophagus and stomach resected, the dissection within the abdomen and the chest was similar allowing assessment of the potential benefits or otherwise for the MIE approach over open surgery. We report the peri-operative outcomes as well as longer-term outcomes in relation to the cancers that were treated.