Video-assisted thoracoscopic esophagectomy: keynote lecture

Abstract

Minimally invasive esophagectomy (MIE) by thoracoscopy after neoadjuvant therapy results in significant short-term advantages such as a lower incidence of pulmonary infections and a better quality of life (QoL) with the same completeness of resection. After 1 year, a better QoL is still observed for MIE in comparison with the open approach, while having the same survival. Seven issues about implementation of MIE for cancer require discussion: (1) choice of the extension of esophageal resection and use of neoadjuvant therapy; (2) reasons to approach the esophageal cancer by MIE; (3) determining the best minimally invasive approach for gastro-esophageal junction cancers; (4) implementation of evidence-based MIE; (5) standardization of the surgical anatomy of the esophagus based on MIE; (6) future lines of research of MIE; and (7) learning process. In the time of imaging-integrated surgery it is clear that the MIE approach should be increasingly implemented in all centers worldwide having an adequate volume of patients and expertise.

Early experience with totally robotic esophagectomy for malignancy. Surgical and oncological outcomes

“…Although the overall mortality and morbidity sustained following esophagectomy has substantively fallen over recent decades, the risks associated with the procedure are still relatively high, mostly in terms of respiratory complications, and anastomotic leakage …”

“…Esophageal surgery has been historically considered a challenge for the surgeon, essentially due to significant rates of morbidity and mortality and dismal oncological outcomes . The introduction of multimodal therapy and especially neoadjuvant chemoradiotherapy (CRT) has considerably improved the outcomes of patients with esophageal malignancy during recent decades .…”

“…Indeed, although esophagectomy was originally considered a relative contraindication to the application of minimally invasive surgery (MIS), in recent years laparoscopy/thoracoscopy has progressively gained popularity, substantially due to favorable perioperative outcomes . Moreover, several concerns regarding oncological adequacy have now been allayed …”

“…Despite this, laparoscopic/thoracoscopic esophagectomy is regarded as a technically high‐demanding surgical procedure that has failed to obtain diffuse acceptance in clinical practice . Recently, robotics has been introduced in surgical practice with the aim of overcoming some of the technical limitations of conventional laparoscopy and thoracoscopy .…”

“…Recently, robotics has been introduced in surgical practice with the aim of overcoming some of the technical limitations of conventional laparoscopy and thoracoscopy . The use of robotic platforms quickly proved to be of great help in expanding the application of MIS for the thoracic phase of the intervention and robot‐assisted surgery has been proven to be a valid option to perform esophagectomy in a minimally invasive manner . Nevertheless, especially with respect to oncological outcomes, substantive data are still lacking, with evidence that is essentially based on single case series without oncological outcomes assessment …”