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Minimally invasive techniques for oesophageal cancer surgery

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Innovative minimally invasive surgical (MIS) techniques have been explored for the purpose of oesophagectomy since the early 1990s, including various combinations of thoracoscopy, laparoscopy or laparoscopic-assisted methods, mediastinoscopy and open thoracotomy and laparotomy. 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 morbidity and mortality rates to open surgical resection have been demonstrated. Selected series have achieved less blood loss, reduction in some postoperative complications, decrease in intensive care and hospital stay, and better preservation of pulmonary function. Clear proof of superiority over conventional oesophagectomy methods however is not forthcoming since comparisons 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 instrumentation and experience, these difficult procedures may become more accessible and widely practised.

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 oesophageal benign tumour resection,2 laparoscopic oesophageal myotomy with hemi-fundoplication for achalasia,3 and laparoscopic or thoracoscopic diverticulectomy for epiphrenic 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 oesophagectomy, primarily because of the technical complexities and uncertain benefits. Cuschieri pioneered MIS oesophagectomy in the early 1990s using the thoracoscopic approach.5, 6, 7 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.

Section snippets

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 cytological

Minimally invasive oesophageal resection techniques

The concept of using a less invasive procedure in oesophagectomy is not new. The debate 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

Patient selection

From a technical standpoint, appropriate selection for MIS methods is essential to avoid intra-operative difficulties and complications. Contra-indications for a thoracoscopic procedure may include extensive pleural adhesions and bulky or locally infiltrative 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

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 discussed from a technical standpoint. Concerns with regards to adequacy of lymphadenectomy also influence the choice of procedure. Thus

Summary

Since the early 1990s, many innovative MIS techniques have evolved for oesophagectomy. Larger series have started to appear in the literature and certainly with improvement 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

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