**Minimally Invasive Esophagectomy**

**Minimally Invasive Esophagectomy**

Rafael Cholvi Calduch, Isabel Mora Oliver, Fernando Lopez Mozos and Roberto Martí Obiol Fernando Lopez Mozos and Roberto Martí Obiol Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

Rafael Cholvi Calduch, Isabel Mora Oliver,

http://dx.doi.org/10.5772/intechopen.69584

#### **Abstract**

Minimally Invasive Surgery (MIS) for esophageal carcinoma has improved the outcome of patients. This approach has been shown to decrease the rate of respiratory complications, the intensive care unit (ICU) stay, and to allow a faster recovery of patients. Also, an improvement in perioperative care has contributed to better outcomes compared to the open approach. MIS has been shown to be as safe as open surgery in terms of resectability, harvested lymph nodes, and overall survival.

DOI: 10.5772/intechopen.69584

**Keywords:** esophageal carcinoma, anesthesia, minimally invasive esophagectomy, thoraco scopic esophagectomy, laparoscopic esophagectomy, surgical technique, prone position, postoperative care, postoperative prognosis

### **1. Introduction**

Neoplasm of the esophagus is one of the most aggressive diseases with poor survival rate despite of the improvements in staging procedures, multimodality treatments, supportive care, and surgical techniques. It is the eighth most common cause of cancer and the sixth leading cause of cancer death worldwide [1]. Patients often are diagnosed at an advanced stage with metastatic disease in more than 50% at the time of presentation. Surgery is the gold standard for treatment both for early stage disease and for advanced disease after chemoradiotherapy neoadjuvant treatment. Surgery of esophageal cancer is probably one of the most demanding and challenging procedure for the surgeon and the patient alike—with a significant morbidity and mortality, particularly in inappropriately selected patients. Surgical treatment must consist on a radical R0 en-bloc esophagectomy associated with a two-field lymphadenectomy [2].

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Traditionally, open approaches have been used to resect esophageal cancer, performed by transhiatal, transthoracic, or combined approach. Esophagectomy is a complex challenge for the surgeon, dealing with wide areas of the neck, mediastinum, and abdomen. Open esophagectomy is considered to be one of the most traumatic oncologic procedures performed in gastrointestinal surgery because of the extent of resection and dissection required [3]. It entails a significant risk of morbidity (at least a half of patients develop complications) and mortality, that ranges from 6–7% in high-volume centers to 20–28% in low-volume centers.

Orringer et al. [4] reported a large series of 1085 patients who underwent open esophagectomy by transhiatal approach, which has served as a standard to compare postoperative outcomes: hospital mortality rate of 4%; 53% of patients were discharged by 10th postoperative day; and an anastomotic leak rate of 13%. The most frequently reported complications of open approach have been pneumonia (21%), respiratory failure (16%), prolonged ventilatory support more than 48 h (22%), according to the report published by Bailey et al. [5].

In an attempt to avoid extensive tissue aggression and reduce the high morbidity and mortality, the minimal invasive approach has been introduced in the field of gastroesophageal surgery [6]. Cuschieri et al. [7] and DePaula et al. [8] were the first to apply a laparoscopic approach to patients with esophageal cancer. Cuschieri et al. performed six subtotal endoscopic esophagectomies through a right thoracoscopic approach with a mean duration of stay in the ICU of 19 h (range 16–26 h) and a median hospital stay of 11 days (8–18 days). DePaula et al. reported a small series of 12 patients who underwent transhiatal esophagectomy conducted by videolaparoscopy with no mortality and minimal blood loss.

Thanks to the improvements in technology and instrumentation, as well as the surgeons' training in advanced minimally invasive procedures, the practice of this technique has been extended since the 1990s. There are several single institution series reports [7–10] (retrospective and prospective) comparing Minimally Invasive Esophagectomy (MIE) versus open surgery [11, 12], and recent meta-analyses [13, 14] that have confirmed the safety and feasibility of the procedure and the advantages of minimally invasive surgery. These reports show that MIE can reduce the mortality and morbidity of open operations as well as allow a faster recovery. All these findings have been confirmed at the only available level I evidence study, the TIME-trial [15].
