Minimally invasive surgical approaches are being increasingly implemented in the management of esophageal disease. The continued challenge for the minimally invasive surgeon is to maintain the fundamental principles of esophageal surgery that have been established with decades of open experience, while avoiding ill-advised shortcuts. The more complex the esophageal intervention, the more likely we are to see difficulty in reproducing the key technical steps of any given minimally invasive procedure. In most cases it is not the intent of the surgeon to perform a less than perfect operation, but one may be prodded by reports from other centers, as well as by patients and referring physicians seeking good results from small incisions. Therefore, as we evolve toward a less invasive culture and embrace new technologies, it is important that we continue to critically interpret and publish our results, while adopting a thoughtful attitude toward accomplishing the best outcomes possible.

This chapter summarizes the role of minimally invasive surgery in the treatment of esophageal cancer. Though laparoscopic fundoplication represents one of the cornerstones of minimally invasive esophageal surgery, this topic is discussed in detail in the chapter on antireflux procedures (Chapter 16). Similarly, other advanced minimally invasive esophageal techniques including esophageal staging techniques (Chapter 2), myotomy with fundoplication for esophageal motility disorders (Chapter 20), diverticulectomy (Chapter 22), palliative esophageal procedures (Chapter 21), and paraesophageal hernia repair with or without gastroplasty (Chapter 35) are covered in this text. The minimally invasive approach to esophagectomy highlighted in this chapter includes a detailed description of operative technique as well as a discussion of the published outcomes with comparison to the comparable open procedures. Complex procedures such as minimally invasive esophagectomy (MIE) are routinely being performed in only a limited number of specialized centers. Prospective studies ultimately will be required to objectively identify the benefits and limitations of these minimally invasive approaches.

Esophageal cancer is the sixth leading cause of cancer-related death world-wide. In the United States, there will be an estimated 17,460 new cases of esophageal cancer diagnosed in 2012, with over 15,070 deaths (ninth leading cause of cancer-related deaths in the United States). The incidence of esophageal cancer increases steadily with age, with the median age of diagnosis being 68 years. Though squamous cell carcinoma has been demonstrated to be four to five times more common in African Americans, the incidence of adenocarcinoma has been increasing rapidly among Caucasians. In the mid-1990s, adenocarcinoma overtook squamous cell carcinoma as the most common type of esophageal cancer in the United States. Risk factors for the development of adenocarcinoma include chronic gastroesophageal reflux disease (GERD), obesity, and the presence of Barrett’s esophagus. Esophageal adenocarcinoma is currently the solid malignancy with the most rapidly increasing incidence in the United States and the Western world, having increased by almost 600% since the 1970s. Overall survival rates, however, remain grim, ranging between 5% and 16%. The introduction of new molecular diagnostic tests in addition to new and emerging therapeutic techniques, and the development of more effective multimodality management strategies, provide hope for earlier identification and hopefully improved outcomes in the management of this lethal condition.

High-grade dysplasia (HGD), referred to by some as carcinoma in situ, is characterized by malignant histologic findings that are confined to the esophageal epithelium and do not penetrate the basement membrane. HGD is believed to represent a late step in the dysplasia-carcinoma sequence, and can exist both as an isolated lesion and in association with invasive cancer. Although not all patients with HGD have, or will develop, cancer, malignant progression has been documented in 16% to 59% of patients followed for more than 5 years. Detection is notoriously difficult due to the lack of visible mucosal changes, and diagnosis is complicated by significant interobserver variability in the interpretation of the pathologic specimens. Esophagoscopy employing the Seattle protocol (four-quadrant jumbo biopsies taken every 1 cm) remains the standard method for evaluating segments of Barrett’s esophagus. When HGD is suspected based upon pathologic evaluation, confirmation of the diagnosis by an independent pathologist is performed.

The principal management options for patients diagnosed with HGD include endoscopic surveillance, mucosal ablation, or esophagectomy. Intensive endoscopic surveillance can be performed every 3 to 6 months in the setting of HGD, with surgical or ablative therapy being employed once there is definitive evidence of adenocarcinoma. Although it is true that not all patients with HGD will go on to develop cancer, by the time biopsy specimens reveal HGD, between 40% and 60% patients will already have an invasive malignancy. Intensive surveillance strategies might avoid the risks associated with esophageal resection, but there has not been a clear demonstration that current intensive surveillance protocols are cost-effective or improve
mortality from esophageal cancer. Extensive work is underway evaluating methods to enhance the yield of surveillance protocols utilizing improved imaging modalities (e.g., fluorescence endoscopy, narrow-band imaging). However, at this time, none of these modalities has been clearly established as the standard of care in the management of HGD and early esophageal cancer.

Endoscopic ablation represents another option in the treatment of HGD or carcinoma in situ. The intent of this procedure is to eradicate the abnormal Barrett’s epithelium to allow for subsequent restoration of normal squamous mucosa. Multiple techniques have been developed to selectively eradicate Barrett’s mucosa and intramucosal carcinomas, including photodynamic therapy, endoscopic mucosal resection (EMR), and radiofrequency ablation (RFA).