Rationale for video-assisted radical esophagectomy

Despite many positive reports on video-assisted esophagectomy (VAE) for malignant esophageal tumors, VAE remains a lesser used procedure in Japan because of its technical difficulty and the strong desire of esophageal surgeons for thorough lymphadenectomy. In this article, we review former reports as well as our own experiences to demonstrate the feasibility and rationale for radical VAE as a standard operation for esophageal cancer. Although the reduction of surgical stress is not clear, it has been reported that VAE is associated with lower morbidity related to postoperative pulmonary complications, and we experienced a shorter period of postoperative systemic inflammatory response syndrome. VAE is advantageous not only because it is less invasive but also because of the possibility of a more meticulous operation through the magnifying effect of the surgical field and the alteration of the viewpoint of the surgeon. The number of dissected lymph nodes, a possible indicator of the extensiveness and thoroughness of lymphadenectomy, is reported to be the same for VAE as for conventional thoracotomy by many surgeons, and our experience was no exception. Although it is too early to discuss the prognostic effect, no obvious disadvantage in prognosis has been reported. We are convinced that radical VAE is not inferior in radicality as an operation for esophageal cancer. As the evaluation of radicality and safety of radical VAE differs somewhat from surgeon to surgeon, different attitudes about the indications for radical VAE remain. We cautiously suggest that use of this new procedure should move forward.