Review of open and minimal access approaches to oesophagectomy for cancer

Background: Minimally invasive approaches to oesophagectomy are being used increasingly, but there remain concerns regarding safety and oncological acceptability. This study reviewed the outcomes of totally minimally invasive oesophagectomy (MIO; 41 patients), hybrid procedures (partially minimally invasive; 34) and open oesophagectomy (46) for oesophageal cancer from a single unit. Methods: Demographic and clinical data were entered into a prospective database. MIO was thoracoscopic-laparoscopic-cervical anastomosis, hybrid surgery was thoracoscopic-laparotomy or laparoscopic gastric mobilization-thoracotomy, and open resections were left thoracoabdominal (LTA), Ivor Lewis (IL) or transhiatal oesophagectomy (THO). Results: There were 118 resections for carcinoma (23 squamous cell carcinoma, 95 adenocarcinoma) and three for high-grade dysplasia. MIO took longer than open surgery (median 6.5 h versus 4.8 h for THO, 4.7 h for IL and LTA). MIO required less epidural time (P < 0.001 versus IL and LTA, P 0.009 versus thorascopic hybrid, P = 0.014 versus laparoscopic IL). Despite a shorter duration of single-lung ventilation with MIO compared with IL and LTA (median 90 versus 150 min; P = 0.013), respiratory complication rates and duration of hospital stay were similar. There were seven anastomotic leaks after MIO, four after hybrid procedures and one following open surgery. Mortality rates were 2, 6 and 2 per cent respectively. Lymph node harvests were similar between all groups, as were rates of complete (R0) resection in patients with locally advanced tumours. Conclusion: MIO is technically feasible. It does not reduce pulmonary complications or length of stay. Oncological outcomes appear equivalent.