Radical thoracoscopic esophagectomy for cancer

Background: 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. Methods: 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 (TINO) but all other cancers were T2 (3) or T3 (19). Dissection of the thoracic esophagus was attempted via a right-sided approach, followed by a laparotomy and a cervical incision. Results: 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%. Conclusions: Radical thoracoscopic mobilization of the esophagus is feasible, but the potential for complications remains high and requires further study.