Esophageal cancer requires a multimodality treatment approach, with surgical resection a key component in many cases. When it comes to esophagectomy, several approaches and techniques exist, including transhiatal versus transthoracic and open versus minimally invasive. Each approach has its associated risks and advantages. When determining the optimal approach and technique, several variables need to be considered. The key variables include patient and tumor characteristics, as well as surgeon comfort and experience with each approach. Regardless of the approach, the goal should remain the same, that is, performing a safe operation without compromise of oncologic principles.
Key points
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Minimally invasive esophagectomy has been described. Regardless of the approach, it is imperative to perform a safe and oncologically sound resection.
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It is important to have a general awareness of risks and advantages of each approach to esophagectomy.
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When it comes to the different approaches to esophagectomy, minimally invasive operations are seen to offer several advantages.
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Several factors can influence the optimal approach; however, the choice of approach largely depends on surgeon comfort and experience.
Introduction
Esophageal cancer has seen an overall increase in incidence over the last several decades. This pattern is more pronounced in the United States and other Western countries. , Currently, the incidence of esophageal cancer in the United States approaches 17,000 per year, with more than 15,000 deaths per year attributed to esophageal cancer. It is the eighth most common cancer worldwide, the eighteenth most common in the United States, and only second to pancreatic cancer in case fatality rate. , The treatment of esophageal cancer revolves around a complex, multimodality approach in most instances, with surgical resection a key component in appropriate patients. With the use of ever improving multimodality therapy, there has been an improvement in long-term survival for those with early or locally advanced disease. This has partly been due to newer chemotherapy agents with lower toxicity profiles, as well as advanced radiotherapy techniques that have developed over the last several decades. Similarly, as other aspects of esophageal cancer treatment have evolved, so has the surgical approach to esophagectomy. Historically, open esophagectomy (OE) by either a transhiatal or transthoracic route has long been the surgical approach to resection; however, over the past several decades, minimally invasive approaches have become more popular, with a greater move toward transthoracic rather than transhiatal routes of resection. Regardless of the approach, the goal should remain the same, that is, performing a safe operation without compromise of oncologic principles. Here we discuss the different approaches and variables that may influence decision making.
Operative approaches
Generally, esophageal resections can be characterized under 2 broad categorizations: transhiatal esophagectomy (THE) versus transthoracic esophagectomy (TTE), and OE versus minimally invasive esophagectomy (MIE). Within these 2 broad categories, subsets of technique exist.
The most common transthoracic operations, those using some component of entry into the right or left lateral chest, include the Ivor Lewis (abdomen and right chest), McKeown or 3-hole (right chest, abdomen, and neck), and right or left (Sweet operation) thoracoabdominal (simultaneous transcostal abdomen and right or left chest). The transhiatal operations are performed through a laparotomy in conjunction with a cervical incision.
Over the last several decades, minimally invasive approaches to esophageal resection have evolved. These approaches were developed to decrease perioperative morbidity, but without compromising oncologic principles. Initially, minimally invasive approaches were used in a limited capacity for small, early stage tumors. With advancements, MIE is often used in advanced cancers as well. MIE includes a large spectrum of approaches. These range from total thoracoscopic and laparoscopic approaches to a variety of hybrid approaches in which the chest approach may be done through a minimally invasive technique, but the abdominal portion remains open, or vice versa. In recent years, robotic approaches to esophagectomy are becoming more popular. Like other MIE approaches, the robot is used either during the chest or abdominal portion, or can be used during the entirety of the resection.
There are a few variables that need to be considered when choosing the approach to surgery for these patients. Ultimately, when resection is performed for malignancy, preserving oncologic principles is key. Regarding robotic resection, the literature continues to expand. Several studies have demonstrated the feasibility of a complete resection. In the ROBOT trial, which represents a randomized controlled trial comparing robotic-assisted MIE (RAMIE) with other traditional approaches, R0 resections were comparable between RAMIE and OE, as well as median lymph nodes retrieved. No difference in overall survival was noted between the 2 groups at 40 months, although longer follow-up will be needed to draw any significant differences.
Open versus minimally invasive esophagectomy
Minimally invasive surgical approaches have been adopted across a wide range of surgical subspecialties. As more physicians became proficient in minimally invasive techniques, several esophageal diseases have been treated in this manner over the past 20 to 30 years; thus, it is no surprise that this has been extended to esophagectomy. As mentioned, the esophagectomy was historically performed in an open fashion, either through the transhiatal or transthoracic approach. However, there are now data that show that these can all be safely performed minimally invasively. , , Regardless of the technique or approach used, it is important for the surgeon to be aware of current data regarding morbidity, mortality, and outcomes. Although this area of research is still active area, there is a growing body of literature outlining these techniques.
The morbidity of the OE can exceed 50% to 70%, with mortality historically ranging from 8% to 23%. , , However, with the advent of high-volume centers of excellence as well as minimally invasive approaches, these numbers seem to be improving. The literature has substantially grown since the first MIE described by Cuschieri and colleagues in 1992. There are now several randomized trials and meta-analyses that show decreased overall morbidity (especially respiratory complications) and shorter hospital stay for MIE, with similar mortality rates. , , , Anastomotic leakage is an important postoperative morbidity that deserves extra attention. Multiple studies have failed to show a significant difference between open and MIE approaches. , , , In regards to anastomotic technique, stapled anastomosis has been shown to be superior to handsewn techniques in several studies. , Although this area of research is still active, it seems MIE has several advantages over the traditional open techniques in terms of short-term morbidity.
Transthoracic versus transhiatal esophagectomy
When examining the different approaches to esophagectomy, they can broadly be grouped into either TTE or THE, with TTE being subdivided into Ivor Lewis or McKeown methods. In a randomized controlled trial by Omloo and colleagues, the TTE was noted to be superior in several aspects, but primarily better lymph node harvest. This finding has been further validated by several other studies and a large meta-analysis. , , Additionally, the TTE has been shown to have a lower anastomotic leak rate when compared with THE. In terms of overall morbidity, THE may be superior. The study from Omloo and colleagues shows less overall morbidity and operative time when the THE approach was used, although this finding has not been routinely replicated in other studies. In a large series by Orringer and colleagues, THE was performed with acceptable morbidity, although anastomotic leak and recurrent laryngeal nerve paralysis was higher compared with those generally reported for Ivor Lewis esophagectomy. The mortality rate of the 2 approaches, however, is largely the same. , ,
As mentioned elsewhere in this article, there are a myriad of surgical approaches to the esophagectomy, and the majority of these can be performed minimally invasively. When comparing the different types of minimally invasive approaches, the transthoracic approaches are subdivided into Ivor Lewis (MIE chest) and McKeown (MIE neck). Although the transhiatal approach can be performed laparoscopically, it is often cited as having poor visibility, often leading to inadequate lymph node dissection and difficulty with hemostasis. Thus, many high-volume centers have transitioned to the transthoracic MIE. The literature comparing the MIE chest and MIE neck is scant. However, a study performed by Luketich and colleagues showed decreased recurrent laryngeal nerve injury and pharyngeal dysfunction in the MIE chest group, with the remaining parameters being similar. Last, robotic approaches have been increasingly used for esophagectomy. Although there is a relative paucity of data regarding its usefulness, several studies show promising results. Early reports have shown RAMIE to offer outcomes similar to other traditional MIE approaches. , , Additionally, it is theorized that some areas of the dissection, especially the mediastinum, may be more effectively performed with the robotic platform, given is superior optics, depth of field, and multiple degrees of freedom. However, although promising, this approach needs to be further vetted.
Location
Esophageal cancer may arise anywhere along the esophagus. Squamous cell cancers more commonly occurs in the proximal and middle esophagus, and adenocarcinomas arise in the mid to distal esophagus. To achieve complete (R0) resections, more proximal tumors traditionally require a cervical anastomosis. This goal can be accomplished through either a 3-hole McKeown or transhiatal approach. Either approach can also be accomplished using minimally invasive techniques. As described elsewhere in this article, cervical anastomosis does have a higher incidence of recurrent laryngeal nerve injury, anastomotic leak, and pharyngoesophageal swallowing dysfunction.
When resecting middle to distal esophageal cancers, any esophagectomy technique and approach, open or minimally invasive, can generally be used and performed. We generally recommend an Ivor Lewis approach because it minimizes the risks associated with cervical anastomosis and provides a superior en bloc lymph node resection. Whether it be open or minimally invasive often depends on the surgeon’s experience and preference.
Pathology
Barrett’s Esophagus and Malignancy
Historically, Barrett’s esophagus (BE) with high-grade dysplasia was an indication for esophageal resection. Today, high-grade dysplasia is frequently treated with endoscopic mucosal resection and ablation of the BE. Indications for esophagectomy in the setting of BE may include multifocal high-grade dysplasia, long segment BE, and a younger patient who may prefer to avoid routine BE surveillance with endoscopic biopsies. Shared decision making between the surgeon and patient would dictate the management in these cases, and a THE with avoidance of the chest and possible pulmonary complications may be offered. Regardless, we prefer to offer a minimally invasive Ivor Lewis approach in these cases to minimize risks of a cervical anastomosis and of laparotomy, including intraoperative cardiac compression, higher splenectomy rate, and long-term risk of ventral hernia.
For locally or regionally advanced esophageal malignancies, the goal is an R0 resection and adequate lymph node harvest for pathologic staging. Histology itself does not directly dictate the approach, but rather the likelihood of a sound oncologic resection. Stage of cancer may impact the surgeon’s selection of approach. Fig. 1 summarizes preferred surgical approaches for esophagectomy in the setting of esophageal malignancy.
Benign Disease
Although less common, occasionally an esophagectomy is warranted for benign disease. Diagnoses include severe refractory reflux disease, end-stage achalasia, severe esophageal dysmotility, and/or stricture. The approach to esophagectomy should be dictated by the disease process. Patients with achalasia or esophageal dysmotility may require a cervical anastomosis to remove all the diseased esophagus. In those undergoing resections for reflux, an Ivor Lewis approach is preferred to avoid complications associated with neck anastomosis. Many patients undergoing esophagectomy for benign pathology have previously undergone one or several prior foregut operations. These may include an antireflux or paraesophageal hernia repair or a modified Heller myotomy. Previous procedures may influence the approach as a completely minimally invasive approach may be impeded by significant scar tissue. In addition, the gastric conduit may no longer be an option after several complex reoperations. Esophagectomy after prior reflux studies has been shown to be associated with greater perioperative morbidity, anastomotic leak, and need for reoperation ; however, Chang and colleagues did not report a difference in occurrence of anastomotic leak. Fig. 2 summarizes preferred surgical approaches for esophagectomy in the setting of benign disease.
