Best Practice & Research Clinical Gastroenterology

Vol. 20, No. 5, pp. 925e940, 2006

doi:10.1016/j.bpg.2006.03.011
available online at http://www.sciencedirect.com

Minimally invasive techniques for oesophageal

cancer surgery

Simon Law* MS, MB, BChir, MA (Cantab), FRCSEd, FACS, FCSHK, FHKAM
Professor of Surgery
Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong SAR, China

Innovative minimally invasive surgical (MIS) techniques have been explored for the purpose of
oesophagectomy since the early 1990s, including various combinations of thoracoscopy, laparos-
copy or laparoscopic-assisted methods, mediastinoscopy and open thoracotomy and laparot-
omy. The myriad of surgical approaches implies a lack of consensus on which is superior. Like
open surgery, it is perhaps more important to have a tailored approach for the individual patient.
MIS oesophagectomy has been shown to be feasible, and at least equivalent postoperative mor-
bidity and mortality rates to open surgical resection have been demonstrated. Selected series
have achieved less blood loss, reduction in some postoperative complications, decrease in inten-
sive care and hospital stay, and better preservation of pulmonary function. Clear proof of
superiority over conventional oesophagectomy methods however is not forthcoming since com-
parisons were often made with unmatched patient cohorts, and a well conducted randomized
controlled trial has not been carried out. It is expected that with further improvements in in-
strumentation and experience, these difficult procedures may become more accessible and
widely practised.

Key words: oesophageal neoplasm; oesophagectomy; minimally invasive surgery; postoperative

morbidity and mortality; survival.

INTRODUCTION

Minimally invasive surgery (MIS) has revolutionized surgical practice, and oesophageal
surgery is no exception. Many minimally invasive procedures dealing with diseases of
the oesophagus have become well established and accepted by the surgical community,
such as laparoscopic fundoplication for gastroesophageal reflux disease,1 thoracoscopic

* Address: Professor Simon Law, Department of Surgery, University of Hong Kong Medical Centre, Queen
Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China. Tel.: þ852 2855 4774; Fax: þ852 2819 4221.
E-mail address: slaw@hku.hk
1521-6918/$ - see front matter ª 2006 Elsevier Ltd. All rights reserved.
926 S. Law

oesophageal benign tumour resection,2 laparoscopic oesophageal myotomy with hemi-

fundoplication for achalasia,3 and laparoscopic or thoracoscopic diverticulectomy for ep-
iphrenic diverticulum.4 For these benign diseases, reducing the trauma of surgical access
has definite advantages; immediate postoperative recovery is enhanced, and equivalent
functional results can be obtained compared to open procedures.
For oesophageal cancer MIS methods potentially can be used for disease staging,
and for oesophagectomy. Progress however has been slow, especially for oesophagec-
tomy, primarily because of the technical complexities and uncertain benefits. Cuschieri
pioneered MIS oesophagectomy in the early 1990s using the thoracoscopic
approach.5e7 Since then many centres have attempted different MIS techniques in
treating oesophageal cancer. The indications, the optimum methods, and their benefits
remain controversial. This review serves to summarize the current status of the use of
MIS in treating oesophageal cancer.

MINIMALLY INVASIVE STAGING TECHNIQUES

Thoracoscopy and laparoscopy have their advocates to stage oesophageal cancer.

Thoracoscopic staging usually involves a right-sided approach, with opening of the
mediastinal pleura from below the subclavian vessels to the inferior pulmonary vein;
lymph node sampling is then performed. Sometimes left sided-thoracoscopy is also
performed to sample lymph nodes at the aorto-pulmonary window. Laparoscopic
staging can include coeliac lymph node biopsy, collection of peritoneal fluid for cyto-
logical examination, and the use of laparoscopic ultrasound for detecting liver metas-
tases. In a study of 53 patients whose staging included conventional CT scan and
endoscopic ultrasound (EUS), minimally invasive staging reassigned a lower stage in
10 patients and a more advanced stage in seven patients (32.1%).8 The multi-institutional
study (CALGB 9380) investigated the use of combined thoracoscopy and laparoscopy
staging in 113 patients, the strategy was feasible in 73% of patients. Thoracoscopy and
laparoscopy identified nodes or metastatic disease missed by CT scan in 50% of
patients, by magnetic resonance imaging in 40%, and by EUS in 30%. Although no deaths
or major complications occurred, staging did involve a general anaesthesia, one-lung
anaesthesia, a median operating time of 210 min, and a hospital stay of 3 days.9
The chance of metastases in the abdomen is considerably more with adenocarci-
nomas of the lower oesophagus and gastric cardia compared to squamous cell cancers
of the oesophagus. Laparoscopy can be of use in diagnosing abdominal metastases like
peritoneal secondaries, or identifying unsuspected cirrhosis, which is a relative contra-
indication for surgical resection for some investigators. Its value is much less for more
proximally located tumours.10
One recent study looked at the cost effectiveness of different combinations of stag-
ing methods including CT scan, EUS, Positron Emission Tomography (PET) scan, and
thoracoscopy and laparoscopy. While PET þ EUS-FNA gave the most accurate staging
combination, it was more expensive than CT þ EUS-FNA. Although thoracoscopy and
laparoscopy could identify some additional patients with advanced disease, the yield
was small.11 This study suggests that initial PET staging is indicated, and if no metastatic
disease is identified, EUS þ/
FNA should be performed. Given that PET scan is still
not widely available, it seems that CT scan and EUS should be the initial staging
modalities, and PET indicated especially in patients found to have locally advanced
tumours with no distant metastases. The invasiveness and cost of thoracoscopy and
laparoscopy, and the constantly improving non-invasive methods like PET scanning,
 MIS techniques for oesophageal cancer surgery 927

make the use of minimally invasive staging less attractive. It should be reserved in cases
where positive confirmation of metastatic disease not otherwise obtained is essential
in deciding on treatment.

MINIMALLY INVASIVE OESOPHAGEAL RESECTION TECHNIQUES

The concept of using a less invasive procedure in oesophagectomy is not new. The de-
bate on whether a transthoracic or a transhiatal approach results in less morbidity and
better outcome has been controversial for a long time.12,13 Two large meta-analyses
concluded that the transthoracic approach probably resulted in higher peri-operative
morbidity and mortality rates, but long-term survival was not different.14,15 The largest
randomized trial published to date compared 106 patients who underwent transhiatal
oesophagectomy with 114 patients who had the transthoracic approach for mid-lower
third/cardia adenocarcinomas. This study suggests that transhiatal resection results in
lower pulmonary complication rates, shorter ventilation duration, intensive care and
hospital stay. There were however no significant differences in in-hospital mortality
at 2% and 4%. Significantly more lymph nodes were dissected in the transthoracic
group (16 versus 31), and there was a trend towards a survival benefit with the trans-
thoracic approach at five years.16 The benefits and drawbacks of a ‘less invasive’ pro-
cedure for oesophagectomy are far from conclusive. The advent of MIS surgery simply
adds to this debate.
Since Cuschieri’s early reports,5e7 many different MIS approaches in oesophagec-
tomy have been devised, including various combinations of thoracoscopy, laparoscopy,
mediastinoscopy, and laparoscopic-assisted (with mini-laparotomy or hand-port de-
vices) or thoracoscopic-assisted methods (with mini-thoracotomy). The myriad of sur-
gical methods implies a lack of consensus on which is superior.17 The most popular is
perhaps thoracoscopic oesophagectomy with gastric mobilization via a laparotomy and
cervical oesophago-gastrostomy.7,18e27 Combining laparoscopic and thoracoscopic ap-
proaches has its advocates,28e30 so does a totally laparoscopic approach.31e33 Hybrid
procedures with MIS-assisted techniques such as the use of hand-ports are also prac-
tised by many.34,35 The results of selected published series are shown in Tables 1 and 2.
Thoracoscopic oesophagectomy is usually performed with the patient in the left lat-
eral position as for a posterolateral thoracotomy, four to five thoracoports are used
and one-lung anaesthesia is used. A laparotomy for gastric mobilization and pull-up
follows.18,19,22,23,36,37 Two groups in Japan have substantial experience with this tech-
nique and reported their results in 80 and 112 patients, respectively,19,37 in whom they
perform extensive three-field lymphadenectomy. Osugi and colleagues utilize an addi-
tional 5 cm mini-thoracotomy at the fifth intercostal space on the anterior axillary line.
This enhances mediastinal exposure; a rigid retractor can be introduced through this
incision for retraction thus enabling safe dissection, especially when dissecting in the
left paratracheal area.37 Kawahara and associates use a five- to six-port technique,
with a 6-cm mini-thoracotomy selectively in difficult cases.19,36 Both groups have re-
ported excellent results (Table 1).
The prone position is advocated by some surgeons.7,25,27 The advantage of this
position is that the lung naturally falls away from the mediastinum, thus improving sur-
gical field exposure without the need for additional retractions. Similarly blood will not
pool within the surgical field. However, the drawback is cumbersome positioning, and
is awkward in the event of an emergent thoracotomy. An Australian group has utilized
this approach in the largest single centre series of 160 patients. The mean
 928 S. Law
Table 1. Selected series using primarily thoracoscopic esophagectomy, with or without a laparoscopic phase.
N Conversion Hoarseness Respiratory Anastomotic Operating Thoracoscopy Blood Lymph Mortality Survival
complication leakage time (min) time (min) loss (mls) nodes
dissected
Cuschieri 1994c 26 1 2 3 1 e e e e 0 e
Gossot 1995 29 0 3 5 5 e 135 200 e 1 e
Akaishi 1996 39 0 7 6 2 448 200 767 19.7 0 e
(mediastinum)
Dexter 1996c 24 2 8 13 2 e 183 e 13 (6e28) 3 e
Law 1997 22 4 4 4 0 e 110 450 7 1 2-yr:
62% (TS)
63% (TT)
Yamamoto 2005 112 1 10 (8.9%) 7 (6.3%) 9 (8%) e 112 112 27 1 (30-day) 5-yr 52%
(thorax) (mediastinal)
3 (hospital Stage I 87.2%
death)
Stage II 70.2%
Stage III 27%
Law 2000a 30 2 e 12 1 392 90 700 e 4 Median
34 mth (TS)
16 mth (TT)
Smithers 2001c 160 20 e 39 (27%) 6 e 104 165 (TS) 11 8 Median 29 mth
1-yr 70%
2-yr 57%
5-yr 40%
Osugi 2003 80 10 55%
early n ¼ 34 14% 29% 3% e 278 428 29 0
late n ¼ 46 15% 6.5% 0% e 183 161 36 0
Luketich 2003d 222 16 (7.2%) 3.6% 9.5% 11.7% e e e e 3 (1.4%) e
(30-day)
Nguyen 2000/2003d 46 2.2% 1 e 8.7% 350 116 279 10.3 4.3% 3-yr 57%
Martin 2005b,c 36 2 e e 19% 240 e 200 e 5.5% 4-yr: 44%
Okushiba 2003e 18 e 16.7% 16.7% e 550 e 550 20.1 e e
(mediastinum)
11.1
(abdomen)
Suzuki 2005e 19 0 4 e 1 476 e 343 e e e
Numbers represent number of patients unless otherwise stated.
TS: thoracoscopic resection, TT: transthoracic resection.
a
For pharyngo-laryngo-oesophagectomy only, four patients also had intra-thoracic oesophageal tumours.
b
Laparoscopic-assisted (n ¼ 21) or open laparotomy (n ¼ 15).
c
Prone position for thoracoscopy.
d
Thoracoscopy and laparoscopy combined.
e
Laparoscopic-assisted with handport with hand introduced into chest for retraction in thoracoscopy phase.

MIS techniques for oesophageal cancer surgery 929

 930 S. Law
Table 2. Selected series using primarily a laparoscopic or laparoscopic-assisted approach without a thoracoscopic phase.
N Conversion Hoarseness Respiratory Anastomotic Operating Blood Lymph Mortality Survival
complication leakage time (min) loss (mls) nodes
dissected
Swanstrom 1997a 9 0 6 5 0 390 290 6 (3e12) 0 e
DePaula 1996a 24 2 2 pneumonia 2 6 256 e 11 4 e
effusion 16
Avital 2005a 22 1 (4.5%) 1 2 1 380 220 14.3 1 e
Van den Broek 2004b 25 36% 2 2 (pneumonia) 5 300 600 7 0 e
Bernabe 2005b 17 0 e e e 336 331 8.7 0 e
Bonavina 2004c 43
(a) 2 e 1 260 28 0 e
(b) 3 1 1 270 13 0 e
Del Genio 2004a 35 4.5% 4.5% 160 400 8 13.6% 23.7 mths
(DFS)
Espat 2005d 15 274 53 0
Figures represent number of patients unless otherwise stated. DFS ¼ disease free survival.
a
Purely laparoscopic oesophagectomy.
b
Lap-assisted with mini-laparotomy.
c
(a) Laparoscopic gastric mobilization with right thoracotomy n ¼ 27, (b) laparoscopic with mediastinoscopic dissection n ¼ 16.
d
Robot-assisted (Da Vinci system) laparoscopic transhiatal oesophagectomy.
 MIS techniques for oesophageal cancer surgery 931

thoracoscopy time was 104 min, blood loss was minimal. Respiratory complication
rate was 27%, and mortality rate was 5%.27
The above methods are modifications of a ‘three-phase’ oesophagectomy with
thoracoscopic oesophageal mobilization, followed by laparotomy and cervical oeso-
phago-gastrostomy. Some investigators also explored the technique of laparotomy
for gastric mobilization, thoracoscopic oesophagectomy and intrathoracic anastomo-
sis.38e41 Performing an intrathoracic anastomosis using thoracoscopy is difficult. In
one report of 17 patients, four out of the five conversions were related to technical
difficulty with the anastomosis. The leakage rate was high at 18%.38,39 One group ini-
tially did intrathoracic anastomosis, but switched to cervical anastomosis after deciding
it was unsatisfactory.42,43 It makes better sense for a much easier cervical anastomosis.
Combining thoracoscopic oesophagectomy with laparoscopic gastric mobilization
and pull-up is also a commonly employed approach, with the group in Pittsburg report-
ing on the largest experience in 222 patients.28 To facilitate the abdominal procedure,
some groups have elected to use a laparoscopic-assisted hand-port system, which may
provide more tactile control and also potentially can shorten the laparoscopic time.34
A useful modification of using a hand-assisted system is for the assistant’s hand to in-
sert via the mini-laparotomy and the retrosternal space into the right thoracic cavity to
help retraction in the thoracoscopic phase of the procedure.44,45
A laparoscopic or laparoscopic-assisted transhiatal oesophagectomy is preferred by
some investigators.32,35,46e49 This allows gastric mobilization and eliminates at least
partly the ‘blind’ area of mediastinal dissection by the introduction of laparoscopic in-
struments through the diaphragmatic hiatus. To a certain extent lower mediastinal
lymphadenectomy can also be performed. It is claimed that adequate dissection can
be carried out to the tracheal bifurcation. The superior mediastinum remains the
area out of reach by the laparoscopic instruments.
A mediastinoscopic method is employed by some surgeons to aid superior medias-
tinal dissection. Two groups in Germany have reported on the use of a specially de-
signed mediastinoscope in oesophageal dissection.50,51 The mediastinoscope, which
is introduced from the neck, has a tissue dilator and several openings for the fibreoptic
bundle, working channel, as well as flushing and suction devices. A shaped groove in the
dilating cone tip allows the mediastinoscope to be guided around the circumference of
the oesophagus. Thermocautery, biopsy forceps and microscissors can be applied
through the working channels, allowing mediastinoscopic dissection to be performed
under magnification. The disadvantage of the technique concerns tumours that are
above the tracheal bifurcation; only small tumours are suitable for the procedure. In
addition, only a limited mediastinal lymph node dissection is possible. This technique
was used initially combined with laparotomy for transhiatal resection,50,51 later modi-
fied for laparoscopic-assisted resection.33,52,53 There are other endoscopic techniques
from the neck. One group describes a method of first making a 10-cm left cervical collar
incision, after the left recurrent laryngeal nerve is identified and the oesophagus
dissected circumferentially; one 5-mm trocar is placed in the suprasternal notch and
one other laterally. Then the cervical incision is closed to prevent gas leakage, and
another 5-mm port is introduced through the centre of this incision. Carbon dioxide
insufflation is used up to a pressure of 4 mm Hg and a conventional 30  , 5-mm endo-
scope is inserted through this central trocar. This method enables better visualization
of the upper mediastinum, and the gentle CO2 insufflation also helps create the dissec-
tion plane.54 In another report, a 5-mm mirror scope attached to a retractor with
a transparent flat tip (Scuba-dissector, Endopath Saphenous Vein Harvest Tray, Ethicon
Endosurgery, Cincinnati, OH, USA) is used to aid upper mediastinal dissection.55
932 S. Law

In general, if a transhiatal oesophagectomy is not preferred, most surgeons would

incorporate a thoracoscopic phase for oesophagectomy to replace the thoracotomy.
However, some have combined laparoscopic gastric mobilization with an open thora-
cotomy for oesophageal extirpation, theorizing that a thoracotomy allows more
thorough mediastinal lymphadenectomy and easier intrathoracic anastomosis.33,56
However, this method is not popular as most would regard avoidance of a thoracot-
omy as more important than replacing the laparotomy.
Robotic-assisted oesophagectomy was reported by two groups,57e59 the first in 15
patients who underwent laparoscopic transhiatal oesophagectomy.58 Conventional
laparoscopic gastric mobilization was first carried out, then using the Da Vinci system
(Intuitive Surgical, Inc., Sunnyvale, CA, USA), mediastinal dissection was performed.
This was combined with conventional transhiatal dissection from the cervical incision.
The mean operating time was 274 min, with the time decreasing to 216 min for the
last seven cases. Blood loss was minimal. No postoperative death occurred. The sec-
ond group reported on only one patient.59 A thoracoscopic oesophageal resection
with mediastinal nodal dissection was first performed with the robotic system; the pa-
tient was then turned supine for the abdominal dissection using the same system. The
total time in the operating room was 11 h, and the total surgical console time was 4 h
20 min. The estimated blood loss was 900 ml. Hospital length of stay was 8 days.

MINIMALLY INVASIVE OESOPHAGECTOMY AND MORBIDITY

Patient selection

From a technical standpoint, appropriate selection for MIS methods is essential to

avoid intra-operative difficulties and complications. Contra-indications for a thoraco-
scopic procedure may include extensive pleural adhesions and bulky or locally infiltra-
tive tumours, especially those in close proximity with the tracheo-bronchial tree.
Some surgeons do not recommend the procedure to patients with prior irradiation,
because tissue planes may be obscured,60 while others do not find this prohibitive.19,48
In many series, early-stage cancers or patients with high-grade dysplasia were prefer-
entially selected, partly because of the technical ease with which these tumours can be
resected.30,47,58,61 In the Pittsburg report, two-thirds of patients had cancer of stage II
and below, 21% had high-grade dysplasia.28
Another technical consideration for patient selection for MIS is the location of the
primary tumour. The changing epidemiology in western countries has led to a predom-
inance of lower third and gastro-oesophageal junction adenocarcinomas,62 while pa-
tients in the East still suffer mostly from squamous cell cancers of the middle
oesophagus.63 It is evident that for most reported series from Asia, thoracoscopic
oesophageal mobilization is an integral part of MIS oesophagectomy,18e20,23,44,45,54,64
while a purely laparoscopic or laparoscopic-assisted transhiatal approach without
a thoracic phase is utilized mostly in the West.32,35,46e49,53 This is obviously in part
related to the perceived ease of oesophageal mobilization in relation to the position
of the primary tumour, and the need for lymphadenectomy. Thorough superior medi-
astinal lymph node dissection is only performed in the East, this is not possible without
a thoracoscopic phase.
Adequate pulmonary function may be required in order to withstand the length-
ened one-lung anaesthesia for thoracoscopic oesophageal mobilization.64 In the lapa-
roscopic technique, the mediastinal pleura is often breached and carbon dioxide
 MIS techniques for oesophageal cancer surgery 933

pneumothorax may occur. In one study of 25 patients with laparoscopically assisted

transhiatal oesophageal resections, entry of the pleura occurred in 93% of patients.
The CO2 pneumothorax resulted in increased end-tidal CO2 and airway pressure
levels and decreased lung compliance, with significantly higher airway pressure com-
pared to a control group of patients who underwent open transhiatal resections.65
The anaesthesiologist should be well aware of this complication and it may be an
important consideration in patients with compromised pulmonary reserve.

Intra-operative complications

Serious intra-operative complications can occur with MIS techniques, such as bleeding
from the azygous vein;21 aorta;7,66 or intercostal vessel;24 injury to the tracheo-
bronchial tree;22,36 recurrent laryngeal nerve;25 and liver and splenic tears.39,43,67
The lack of tactile control is probably a contributory factor. On the contrary, the in-
creased magnification and excellent visualization offered by thoracoscopy might in fact
help lessen complications. Technical complications are obviously operator-, technique-
and instrument-dependent. More recurrent laryngeal nerve injury with thoracoscopy
has been reported with MIS, which was attributed to increased use of diathermy.25 On
the contrary, others also claimed that the use of MIS techniques could reduce this
complication. In one study, transient hoarseness was reduced from 80% to 18%,23
and in the another, transmediastinal endodissection reduced hoarseness from 13%
to 8%.50,68 The increased magnification and excellent visualization offered by thoraco-
scopy or mediastinoscopy were given as reasons for these successes. Judicious use of
other energy sources like harmonic scalpel or bipolar scissors may also help reduce
this complication. As surgical techniques mature and instrumentation improves, the
chance of intra-operative mishaps will likely reduce.
Surgeons must be prepared for conversion to open surgery should difficulties be
encountered and modify their technique accordingly. The need to convert to open sur-
gery is required in approximately 10% of patients in various series. The reasons re-
ported for conversion included lung adhesions,18 intra-operative injury to adjacent
structures or bleeding, advanced tumours,18 loss of one-lung ventilation,24 and equip-
ment failure.69 Difficult intrathoracic anastomosis also warrants conversion because
this procedure is technically demanding using MIS methods.39 Although an innovative
technique has been devised to circumvent this difficulty,70 most surgeons prefer a
cervical anastomosis. This point has been discussed.
It seems that serious intra-operative complications can occur with a variety of tech-
niques, but it is difficult to compare these data properly and draw firm conclusions be-
cause of the large variation in methods used by each group. The surgical teams also
had very different levels of experience with open oesophagectomy, which could affect
their success rates.

Postoperative morbidities

Patients who undergo oesophagectomy are often elderly, may have co-morbid dis-
eases, and are malnourished from malignant dysphagia. Aside from gross technical
complications, cardiopulmonary problems are the main causes of death.71e74 Obviat-
ing the need of a thoracotomy or laparotomy may potentially reduce postoperative
pain, ventilator dependence, cardiopulmonary complications, shorten intensive care
and hospital stay, and result in lower mortality rates.
934 S. Law

Many published studies simply document the results of MIS oesophagectomy, and
often satisfactory outcomes are reported. Few studies have directly compared postop-
erative outcome in patients who had MIS with those who underwent conventional
oesophagectomy. One study, comparing the outcome of 22 patients who had thoraco-
scopic oesophagectomy with 63 patients who underwent open thoracotomy resections
during the same time period (but with different selection criteria), did not find significant
differences in morbidity and mortality rates. It was noted, however, that blood loss was
slightly less in the thoracoscopy group,18 and that the group selected for thoracoscopy
had poorer Eastern Cooperative Oncology Group (ECOG) performance status. In
another comparison of patients who underwent pharyngo-laryngo-oesophagectomy
(most of whom had cervical oesophageal, hypopharyngeal or laryngeal cancers), and
a historical cohort of patients, there were also no significant differences.20 The ‘extra-
thoracic’ trauma in this group of patients was substantial, and this may in part explain
the lack of benefit thoracoscopic mobilization was expected to show.
In another study 18 patients who had combined thoracoscopic and laparoscopic
oesophagectomy were compared with two historical cohorts of patients who had un-
dergone either transthoracic or transhiatal oesophagectomy.29 Patients who had the
combined approach had shorter operative time; less blood loss; fewer transfusions;
and shortened intensive care unit and hospital stay compared with the historical con-
trols, while anastomotic leakage rates and respiratory complication rates were similar.
Because the study had the inherent bias of using historical controls it is difficult to
draw firm conclusions.
Osugi and colleagues showed that thoracoscopic oesophagectomy took longer, but
blood loss and morbidity rates were similar compared to open three-field oesopha-
gectomy.26,75 One recent study looked at 17 patients who underwent laparoscopic-
assisted transhiatal resection (with a 8-cm mini-laparotomy) and compared with a
historical group of 14 matched patients who had open transhiatal oesophagectomy.47
Less blood loss, shorter operating time, and a shorter hospital stay were demon-
strated. The 14 control patients however were identified in a 12-year period prior
to MIS oesophagectomy and operative techniques and peri-operative care could
have changed. In addition, the MIS part of the oesophagectomy only involved
10e12 cm of oesophageal dissection in the lower mediastinum using laparoscopy,
the rest of the transhiatal mobilization was completed in the conventional manner
via the laparotomy wound. It is unlikely such an approach will result in superior
outcome.
Another study compared laparoscopic-assisted transhiatal resections in 25 patients
with a historical cohort of 20 patients who had undergone conventional transhiatal re-
section. Operating time in the former group was longer, blood loss was less, and
shorter intensive care unit stay was found. No differences in morbidity, mortality
and hospital stay were documented.35 Again use of a historical control group is unsat-
isfactory. More importantly there was a 36% conversion rate mainly because of tech-
nical difficulties encountered. Appropriate comparisons between the two groups were
thus unreliable.
The use of endodissection with the mediastinoscope lessened cardiac complica-
tions in one study, from 19.3% using conventional transhiatal resection, to 4.2%
with endodissection.50,68 Other complications were not reduced, and only distal oe-
sophageal tumours were studied. Akaishi and colleagues found that the incidence of
recurrent laryngeal nerve injury was less, and that patients were less ventilator-
dependent after thoracoscopic resection compared with a historical cohort. The
overall incidence of pulmonary complications was reduced from 33% to 20%.23
 MIS techniques for oesophageal cancer surgery 935

Conventional thoracotomy reduces chest wall compliance, vital capacity and total
lung capacity. Restrictive pulmonary damage was less following thoracoscopic sur-
gery,26 and spirometric and exercise tolerance was also better in MIS treated pa-
tients.75 Quality-of-life measured by Zubrod score was well maintained in patients
who underwent thoracoscopic oesophagectomy.64 Short- to medium-term quality-
of-life scores, however, could not be shown to be better than after conventional
open surgery in another study.76
Studies with well-matched control groups are lacking in reported series, and de-
spite most studies showing reasonably good results with MIS techniques, clear advan-
tages over conventional open surgery are not seen. This may be partly because of the
number of patients studied generally was too small to have enough statistical power to
demonstrate a difference. There are also other reasons why benefits are difficult to
confirm. With modern analgesic methods such as epidural analgesia, postoperative
pain control is a less critical problem.77 The genesis of cardiopulmonary complications
is multi-factorial and does not depend solely on the size of the incision. Surgical trauma
of mediastinal dissection, more likely the major determinant of ‘surgical invasiveness’,
is also independent of the incision size. The benefit of smaller port sites compared
with open thoracotomy may be offset by the lengthened time of single-lung anaesthe-
sia. It is well recognized that during one-lung ventilation, hypoxaemia can occur. During
an open approach, the collapsed lung can be episodically re-inflated. This does not take
too much time because the lung can be deflated again with manual compression. In
a thoracoscopic approach, deflation and re-inflation requires more time and surgical
dissection has to be halted because of inadequate exposure. The addition of a low con-
tinuous positive airway pressure (CPAP) to the non-dependent lung could improve ox-
ygenation, but surgical exposure is also compromised.78 The use of a prone position
improves surgical exposure, and at the same time CPAP can be applied. In the large
series reported using the prone position, however, respiratory complications were still
substantial.27 A learning curve obviously exists for such complicated procedures.37,23
The duration of the thoracoscopic procedure, blood loss, the incidences of postoper-
ative pulmonary infection were all less, and the number of mediastinal nodes retrieved
was more, in the later half of a group of 80 patients who had thoracoscopic oesopha-
gectomy.37 It was claimed by one investigator that the first 17 cases were necessary to
acquire the basic skills, with the most remarkable difference seen between the first 36
cases and the others.37,64 Thus for most series the full technical potential may not have
been realized.

ONCOLOGICAL CONSIDERATIONS IN MIS OESOPHAGECTOMY

Perhaps the most important consideration for MIS oesophagectomy is whether MIS
oesophagectomy offers comparable oncological clearance to open surgery. Whatever
the technique used, the extent of lymphadenectomy should not be adjusted because of
limitation of the surgical technique.
The importance of patient selection for MIS oesophagectomy has already been dis-
cussed from a technical standpoint. Concerns with regards to adequacy of lymphade-
nectomy also influence the choice of procedure. Thus high-grade dysplasia in Barrett’s
oesophagus, or intramucosal, superficial cancers are preferred by many investigators,
since the chance of lymphatic spread is minimal,28,47,55,58,61 and a laparoscopic or
laparoscopic-assisted approach is often used. However, for the same reason, one
might prefer an endoscopic, organ preserving resection. If more extensive
936 S. Law

lymphadenectomy is deemed necessary for more advanced tumour or for more prox-
imally located tumours, laparoscopy alone offers inferior exposure without additional
thoracoscopic dissection.28,61 Some surgeons include patients with increased medical
risk, even if they have more advanced tumours. In these patients, postoperative recov-
ery and survival are perhaps more important than performing a radical resection.18,55
Palliative resections using MIS methods have also been advocated; again in these pa-
tients faster postoperative recovery and quality-of-life issues such as less post-thora-
cotomy pain, are more important.32
A surrogate of the extent of dissection is the number of lymph nodes removed at
surgery. Radical lymph node dissection is certainly possible, even in difficult areas like
the left paratracheal region along the left recurrent laryngeal nerve.23,36,64 In fact, the
higher magnification under thoracoscopy by keeping the camera close to the oper-
ating field, may allow finer dissection and improve the dissection along the recurrent
laryngeal nerve.23,26 The quality of lymphadenectomy is difficult to evaluate in the
literature. Many do not report on the number of nodes retrieved, and in those
who do the number of mediastinal, abdominal or cervical nodes are not separately
stated. The problem of using the number of lymph nodes as a surrogate is that the
number examined in part depends on the conscientiousness of the pathologist ex-
amining the surgical specimen, and unless comparisons are made with a concurrent
cohort of patients undergoing open surgery, additional bias may be present when
historical records are used.
The ultimate test of minimally invasive oesophagectomy is whether long-term sur-
vival is similar to that of conventional open oesophagectomy. Thus far in series that
report their medium to long-term results, or in those where comparative data with
open surgery are presented, this seems to hold true.18,20,64 Only in one report on
the use of endodissection, the investigators showed that for patients with lower oe-
sophageal adenocarcinomas, and positive lymph nodes, endodissection resulted in lon-
ger survival compared with conventional transhiatal technique.50
Port-site recurrence as a specific problem with MIS has also been reported for
oesophageal cancer.18,19,34,79,80 Direct parietal seeding by repeated passing of
dissecting instruments through the ports seemed to be the mechanism. With
improvement in surgical technique and care taken to protect the port sites, this
has become rare.

SUMMARY

Since the early 1990s, many innovative MIS techniques have evolved for oesophagec-
tomy. Larger series have started to appear in the literature and certainly with im-
provement in instrumentation and experience, encouraging results are now
shown. In appropriately selected patients, MIS oesophagectomy is certainly feasible
and at least equivalent postoperative morbidity and mortality rates, and so far
survival data, can be demonstrated. It is unlikely that MIS methods will significantly
reduce mortality rates, since in experienced centres death from oesophagectomy
has become very uncommon. In selected series, postoperative respiratory complica-
tion rates can be very low. Without a well conducted randomized trial, however, this
potential benefit is difficult to prove. Softer end-points, such as less blood loss, re-
duction in intensive care or hospital stay, analgesic requirement, spirometric and pul-
monary function derangements, biochemical changes,81 and short- and medium-term
quality of life parameters, are more commonly demonstrated. Because of the
 MIS techniques for oesophageal cancer surgery 937

technical complexities of these procedures, they should not be attempted without

training and mentorship, and should be investigated further in centres with adequate
experience with the resections. Further evaluation of the role of minimally invasive
techniques in oesophageal cancer would require larger-scale studies, preferably ran-
domized controlled trials.

Practice points

 A variety of minimally invasive techniques have been explored to perform

oesophagectomy and the method used should be individualized for patients
 Patient selection and choice of procedure are important to enable safe
resection
 Less blood loss, shortened intensive care and hospital stay, less postoperative
pain are the most commonly shown parameters that derive benefits from MIS
surgery
 Because of the complexities of the surgery, their practice should be explored in
centres with adequate experience with open oesophagectomy

Research agenda

 Further research into refining instrumentation and techniques is expected to

improve the results from MIS oesophagectomy
 The impact on important variables like postoperative respiratory complica-
tions, oncological equivalence to open surgery, and survival should be clarified.
 Randomized controlled trials comparing with open oesophagectomy are
needed

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