Evolution and refinements in minimally invasive esophagectomy: a narrative review

Morbidity from traditional open esophagectomies has led to the development and growth of the minimally invasive approach. As this technique has become more widely used over the last few decades, a better understanding of its utility and its effect on patient outcomes continues to take shape. The aim of this narrative review is to discuss how minimally invasive esophagectomy (MIE) has developed as a technique, how patient outcomes have changed over time, and what progress is currently being made in the perioperative adjuncts to improve patient outcomes.

A search was conducted using PubMed and Google Scholar to identify studies pertaining to the advancement of MIE. No restriction was placed on a particular time frame given the historical aspect of the review. Emphasis was placed on randomized controlled trials, prospective studies, meta-analyses and systematic reviews performed within the past 10 years for discussion regarding recent developments and updates in the field.

MIE has been key in reducing pulmonary morbidity and overall post-operative complication rates compared to open esophagectomy (OE). The development of robotic-assisted minimally invasive esophagectomy (R-MIE) shows promise in improving oncologic outcomes by attaining greater lymph node yield. However, success of these procedures is associated with a learning curve that can be a barrier to achieving these outcomes and is difficult to overcome in low-volume centers. Additional interventions that can potentially improve the results of MIE include the introduction of enhanced recovery after surgery (ERAS) programs, early nutrition, and gastric preconditioning, which have demonstrated promise in improving outcomes, such as reduced anastomotic leaks, and pulmonary complications, but warrant further randomized studies.

MIE has proven beneficial in reducing the morbidity of esophagectomies without compromising the oncologic outcome of patients with esophageal cancer. The introduction of R-MIE offers the possibility of further improving outcomes with greater dexterity and visualization. Nonetheless, the learning curve for such a procedure is steep and is an obstacle in achieving overall favorable patient outcomes. Refinements to the minimally invasive technique are currently in development and show promising evidence in reducing the morbidity of esophagectomies.