Evidence base for minimally invasive esophagectomy for esophageal cancer

Surgery remains the mainstay of potentially curative treatment of esophageal cancer; however, esophageal resection is still associated with a relevant morbidity and mortality. Furthermore, patients frequently suffer from concomitant comorbidities and present in a reduced nutritional status. The rationale of minimally invasive surgery is the reduction of surgical trauma with subsequent minimization of (pulmonary) complications and mortality without compromising oncological quality. Minimally invasive esophageal resection was established nearly two decades ago and since then some centers worldwide have adopted this approach as the preferred option for surgical treatment of esophageal cancer. Minimally invasive esophageal resection can be safely performed and provides excellent results in experienced hands. Currently, there is only one randomized trial available comparing open and minimally invasive resection. It was demonstrated that the latter significantly reduced pulmonary complications with comparable mortality and oncological outcome. However, in the majority of studies these convincing results could not be confirmed. Reduced blood loss and a shortened hospital stay were shown to be the main advantages of the minimally invasive approach. Due to technical modifications, patient selection and a remarkable heterogeneity of current studies, a final conclusion on the value of minimally invasive esophagectomy is difficult to be drawn. Based on the current evidence, a noncritical use of minimally invasive resection for esophageal cancer cannot be recommended; however, in selected patients and with appropriate expertise this approach is at least comparable to open esophagectomy.