Radical thoracoscopic esophagectomy for cancer

Much of the morbidity of conventional esophagectomy for cancer is thought to relate to the thoracotomy wound and while transhiatal esophagectomy removes the need for a thoracotomy, it is not oncologically sound. Videothoracoscopy could potentially provide an oncologically sound means for resecting the thoracic esophagus without the need for a thorcotomy.

Between June 1991 and June 1994, thoracoscopic mobilization of the thoracic esophagus combined with radical lymphadenectomy was attempted in 24 patients as part of three-stage esophagectomy for cancer (5 squamous and 19 adenocarcinomas). Mean age was 59 years (range 43-76). Eight patients were ASA grade I, 10 were ASA II, and 6 ASA III. Two patients had early lesions (T1N0) but all other cancers were T2 or T3. Dissection of the thoracic esophagus was attempted via a right-sided approach, followed by a laparotomy and a cervical incision.

The thoracoscopic procedure was successful in 22 patients; it was abandoned in one patient with dense pleural adhesions and in another with inoperable tumor. Mean duration of the thoracic component was 184 min(120-330). There were three post-operative deaths. Ten further patients had major complications. Median post-operative stay was 18 days(9-129). Mean node harvest was 13 nodes(6-28). Two-year survival (cancer specific) was 33%.

Radical thoracoscopic mobilization of the esophagus is feasible, but the potential for complications remains high and requires further study.