Thoracoscopic surgery for esophageal cancer.

Esophagectomy is the appropriate treatment for patients with resectable esophageal cancer. In common with conventional surgeries, controversy exists about what is the best approach and extent of the dissection. For many years, the procedure of choice for the incision has been the Ivor Lewis procedure, later modified. The tumor is resected through a right thoracotomy combined with a laparotomy with cervical esophagogastric anastomosis. The advantage of this operation is that the perfect exposure allows complete esophageal dissection and possible en bloc lymphadenectomy. Although the benefit of an extended lymphadenectomy for thoracic esophageal cancer remains to be proven by a prospective randomized study, there is evidence that survival is better after extended rather than conventional lymphadenectomy. The disadvantages are pulmonary complications related to the necessary thoracotomy and collapse of the right lung. As esophagectomy is invasive, major complications including anastomotic leakage, recurrent laryngeal nerve injury and myocardic infarction are frequent. Regardless of the approach, esophagectomy with lymphadenectomy is associated with considerable morbidity and mortality. Pulmonary complications can be overcome by a transhiatal approach, as described by Orringer et al., in which the esophagus is dissected free through the enlarged hiatus. After an esophageal-proximal gastric resection, the gastric tube created is anastomosed with the cervical esophagus through a combined cervical-abdominal approach, thus avoiding a thoracotomy. DePaula et al. were the first group to report on a large series of patients undergoing laparoscopic transhiatal esophagectomy. However, the disadvantages of the transhiatal approach are the partly blind dissection of the esophagus and the tumor. It is also limited to tumors of the distal esophagus. Thoracoscopic Surgery for Esophageal Cancer