Transmediastinal approach for esophageal cancer: A new trend toward radical surgery

Esophageal squamous cell carcinoma (ESCC), the most common histology of esophageal cancer in Japan and Asia, shows extensive mediastinal spread from an early stage. Therefore, transthoracic esophagectomy with extensive mediastinal lymphadenectomy, including in the upper mediastinum along the recurrent laryngeal nerves, is the gold standard of radical surgery for ESCC. Minimally invasive thoracoscopic esophagectomy has now become a standard option for ESCC. However, transhiatal esophagectomy is regarded as less invasive because it avoids thoracotomy. Yet, it is also considered less curative because it offers a limited surgical view and insufficient mediastinal lymphadenectomy even when conventional specialized mediastinoscopy is used. Recent clinical studies on radical esophagectomy without thoracotomy for ESCC have been reported from Japan. The introduction of novel minimally invasive techniques for the transcervical or transhiatal approach, such as single-port or robotic surgical devices, have enabled transmediastinal radical esophagectomy for ESCC. This review focuses on the transmediastinal approach for esophageal cancer surgery, which employs minimally invasive techniques to reduce morbidity, and its application to radical surgery for ESCC.