Totally 3D HD minimally invasive esophagectomy for thoracic esophageal cancer after neoadjuvant [301804]

Totally 3D HD minimally invasive esophagectomy for thoracic esophageal cancer after neoadjuvant

chemoradiotherapy

Florin Achim1, Mircea Gheorghe1, Adrian Constantin1, Petre Hoara1, Cristian Popa1, Abdulah Alkadour1, Iuliana Vergu2, Adelina Birceanu3, Silviu Constantinoiu1

1. [anonimizat], Sf. [anonimizat], Romania

2. [anonimizat]. [anonimizat], Romania

3. [anonimizat]. [anonimizat], Romania

Corresponding author:

[anonimizat], Sf. [anonimizat], Romania

E-mail: [anonimizat]

Telephone: +[anonimizat]

Introduction: Esophagectomy is a [anonimizat]'s condition, [anonimizat]. Minimally invasive esophagectomy (MIE) may lead to a reduction in perioperative morbidity and mortality with a very good quality of life. Material and Method: We present the experience of the Center of Excellence in Esophageal Surgery regarding total (MIE) [anonimizat] a series of minimally invasive procedures for esophageal neoplasm. Results: We present the total minimally invasive thoracolaparoscopic esophagectomy procedure (modified McKeown), [anonimizat]. Operative times were: thoracic – 120 minutes, abdominal – 130 minutes and cervical – 50 minutes with a total of 360 minutes. The blood loss associated with the procedure was 200ml. [anonimizat] 6 postoperative and discharge in day 10 postoperative without any symptomatology. [anonimizat]-up was without postoperative complications. Conclusions: Solid experience in open esophageal surgery provides a better learning curve and allows complex minimally invasive surgical procedures so that perioperative morbidity can decrease. [anonimizat], [anonimizat] a good postoperative quality of life. Long-[anonimizat], at least equivalent for these patients.

Keywords: [anonimizat]-[anonimizat], McKeown modified triple approach

Introduction

Minimally invasive esophagectomy (MIE) has a history of 26 years of continuous development and improvement ([anonimizat], 1992) and is a [anonimizat]-chemotherapy [1,2 ]. The association of MIE with a [anonimizat], [anonimizat] t years, [anonimizat], minimally invasive esophagectomy (MIE) [anonimizat] 82% of patients are treated with a minimally invasive approach [3]. Simplification of postoperative care ([anonimizat]ic treatment), shorter hospitalization and faster social reintegration recommend the technique as a first indication in early esophageal neoplasms.

In its evolution to become totally minimally invasive procedure, esophagectomy has benefited from the use of video-assisted thoracoscopic surgery (VATS) for overcoming thoracoscopic difficult operating times or laparoscopic mobilization of the stomach, such as hand-assisted laparoscopic surgery (HALS) or robotic assisted minimally invasive esophagectomy (RAMIE) or even extracorporeal preparation of the gastric graft.

The different localizations of the esophageal tumors also dictate the type of surgical approach and within the minimally invasive approach from the introduction of the technique into the current practice the reproduction of all types of classic esophagectomy was performed, including the robotic assisted MIE [4-6].

The classic approach in the treatment of resectable esophageal cancer has been used in the Center of Excellence in Esofageal Surgery at the Clinical Hospital "St. Maria" Bucharest, in the last 30 years with very good outcomes based on experience achieved by managing dificult cases in esophageal diseases. Starting with 2015, we introduced the minimal invasive esophagectomy using the modified McKeown triple approach in order to reduce the rate of postoperative pulmonary complications [7].

The triple modified McKeown thoraco-laparoscopic approach provides an excellent visual field for mediastinal lymphadenectomy and avoids complications associated with intrathoracic anastomotic leakage that can cause significant postoperative morbidity and mortality. We prefere performing a cervical eso-gastric anastomosis, although this is associated with significant swallowing and tracheobronchial aspiration that can increase the risk of lung complications, but fistular complications of cervical anastomosis can be treated conservatively and endoscopic dilatations with Savary bougies can be performed under interventional radiology control for stenosis associated with leak healing.

We present the experience of the Center for Excellence in Esofagic Surgery about minimally invasive esophagectomy through the triple modified McKeown approach, entirely thoraco-laparoscopic, as an initial experience, from a series of minimally invasive procedures for the treatment of esophageal cancer. Over the past 3 years, we have performed this operation using a 2D video camera and recently we are using a 3D HD camera with fewer lung and parietal complications and with a reduced duration of admission to ATI and shorter hospitalization compared to open esophagectomy. The mortality rate was comparable to the open approach. Short term oncology outcomes are also similar.

Case presentation

A 65 years old patient, smoker, addicted to ethanol, diagnosed tomographic and endoscopic in another hospital with gastric ulcer and moderately differentiated lower-esophageal carcinoma of the lower esophagus was admitted in our clinic for epigastralgia, grade I dysphagia and weight loss.

Clinical examination whowed no abnormalities. Laboratory analyzes for liver and kidney function evaluation were within normal limits.

The upper digestive endoscopy revealed at 32-37 cm from incisors, a ulcerated ulcerative tumor above about 1/4 -1/2 of the circumference, and in the stomach, an ulcer of about one cm on the gastric angle of the small curvature, with well-cut edges and mucosal congestion surrounding. There is also a polypodial formation of about 6-7 mm at the DII level. The result of gastric ulcer biopsy does not detect malignant elements, and the Helicobacter Pilory test is positive for 3+.

The barium swallow evidenced in the lower third of the thoracic esophagus, on a length of about 5 cm, large ulceration, a lacunar image and a malignant spine and a niche picture at the level of the small vertical curves, above the gastric angle. Barium swallow is very important for assessing tumor localization and topography and for assessing the future gastric conduit.

The ultrasound endoscopy we routinely practice for establishing tumor invasion in the stratigraphy of the esophageal wall and the evaluation of peritumoral lymphnodes identified a lower esophageal tumor located at about 34 cm from incisors, of about 4.2 / 2.2 cm with the hypoecogenic, non-homogeneous and the invasion of muscularis propria up to the level of adventitia it does not seem to overcome it. Peritumoral, a well-defined oval adenopathy, a 1.5 cm hyperecogene node with malignant malignant aspect and another infracarinar adenopathy with a diameter of about 10 mm and a benign aspect.

Computed tomography of the thorax, abdomen and pelvis confirmed the topography of the esophageal tumor and did not detected secondary pulmonary or parenchymal abdominal metastatic deposits. The final clinical staging is inferior thoracic esophageal squamous cell carcinoma moderately differentiated cT3N1M0.

The multidisciplinary meeting recommended neoadjuvant treatment, the patient performed chemotherapy with Taxol-Carboplatin and radiotherapy with a modulated intensity of 45Gy / 25 fractions / 5 weeks. Six weeks after neoadjuvant oncology treatment, it was re-evaluated in the clinic for surgical treatment.

Figure 1. Upper gastro-intestinal endoscopy (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 2. Barium swallow (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 3. CT thorax pre-irradiation sagital view (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Preoperative clinical and paraclinical evaluation

After 25 radiotherapy sessions and 5 chemotherapy courses, the patient is clinically and paraclinically re-evaluated. The endoscopy revealed two small esophageal tumors at 33-35 centimeters from incisors and the complete healing of gastric ulcer. The barium swallow revealed two lacunar images in the lower third of the thoracic esophagus. The toraco-abdominal CT scan indicates a regression in dimensions of the esophageal tumor thickening with decreased iodophilia at this level without CT detectable secondary determinations. Tomography combined with positron emission (CT-PET) is not routinely performed, but it can prevent a surgery without an oncological benefit.

Figure 4. CT thorax post-irradiation transversal view. Dimensional regression of the esophageal tumour (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Preoperative assesment

Preoperative renal and hepatic function, hemoleucogram, coagulation are within normal limits and pulmonary radiograph and electrocardiogram, spirometry are performed, which showed a mild obstructive ventilator dysfunction and nasal, oropharyngeal and anal probes were taken. Preoperative preparation involves administration of low molecular weight heparin (LMWH) and respiratory gymnastics exercises.

Operative technique

Subtotal minimally invasive thoraco-laparoscopic esophagectomy with esophageal reconstruction with whole stomach was performed under AG IOT (16.07.2018 / CO 720) using the modified McKeown's triple approach with cervical esophagus-anastomosis and feeding jejunostomy.

The surgical instruments set for minimally invasive interventions contains besides the standard 3D laparoscopic 3D HD camera, the trocars Thoracoport 11.5-12 mm for the thoracoscopic approach, the 45 mm EndoGIA vascular stappler with a white or gray cartridge (for azygos vein and left gastric artery and 5 mm long endoscopic Ligasure, very useful in performing mediastinal lymphadenectomy and laparoscopic mobilization of the stomach. The duration of surgery can be reduced by using the use linear GIA and EndoGIA staplers with 60 mm blue or green cartridge depending on the thickness of the gastric wall for the preparation of the gastric conduit when resecting the small curves with creation of gastric tube and the EndoFan which is very useful for retract of the right lung or the liver during dissection of the esophagus junction.

We present details of the technique of esophagectomy with thoracoscopic lymphadenectomy by modified triple approach and laparoscopically assisted gastric pull-up. For the thoracoscopic approach we used the position of the left lateral decubitus and for the laparoscopic and cervical approach the position of the dorsal decubitus.

We use an epidural catheter for additional analgesia. After fitting it and the onset of general anesthesia with selective orotracheal intubation with the Carlens probe, we introduce an intraesophageal thick Fauchet tube that will be useful during the mediastinal dissection of the esophagus. With the right lung exsufflated through selective intubation, the thoracoscopic stage begins after the patient's positioning in the left lateral decubitus and the insertion of the optic trocar in the right hemithorax so that there is enough distance between them avoiding as much as possible conflicts between the surgical instruments during surgery. Five working trocars are used as follows: 10 mm optical trocar (10 mm camera) in the 8th intercostal space anterior to the middle axillary line; working trocar of 10 mm, in the 9 th intercostal space behind the posterior axillary line; working trocar of 10 mm in the 7th intercostal space, ahead of the anterior axillary line; a 10 mm work trocar in the 4th intercostal space on the anterior axillary line for the "fan" endoscopic spacer to retract the anterior lung and allow the esophagus to expose; working trocar 5 mm anterior and inferior to the shoulder blade, used for insertion of traction and contraction instruments.

Figure 5. The position of trocars during thoracoscopy (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

The positioning of working trocars is especially important during the thoracoscopic period in which we have to fight the stiffness of the walls of the right thoracic cavity. After the right lung is collapsed, the anatomical elements are identified: the azygos vein, thoracic esophagus, the main right and left bronchi, the trachea, the pulmonary pedicles. For additional lung collapse, insufflation with CO2 up to a pressure of 8 mmHg can be used. It assesses the macroscopic appearance of the esophagus in order to highlight any signs of extra-adventitial invasion or perisophageal adenopathy. The triangular ligament and upper and lower mediastinal pleura are incised and the right lung adhesions are carefully cut to avoid damaging the lung, which may cause postoperatively the occurrence of an airway leak.

Figure 6. Incision of the triangular ligament of the lung (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 7. Incision of mediastinal pleura (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 8. Section of the azygos vein (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 9. Section of esophageal arteries using the Ligasure (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

After the section of the azygos vein, the circumferential esophagus is dissected along its entire length, in block with perisophageal lymphoid tissue, facilitated maneuvering by isolating it with a Penrose tube. The esophagus is released from almost close, both in the cranial and caudal direction, with the vascular pedicle hemostasis while practicing the mediastinal lymphadenectomy with the help of the Hook monopolar electrode, Ligasure punch and ultrasonic dissector. To perform a thorough hemostasis will use EndoClips for posterior aorticoesophageal vessels or Ligasure brush to prevent postoperative haemorrhage or chilothorax.

Figure 10. Isolation and disection of the upper esophagus (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 11. Identification of the thoracic duct (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 12. Disection of inferior esophagus (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 13. Mediastinal lymphadenectomy (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 14. Pleural drainage (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

After complete esophagus dissection, the pleural cavity lavage is performed, haemostasis is controlled and two drain tubes are installed at Beclaire aspiration drainage, one at the base of the lung and the other at the apex. The pulmonary expansion is directly observed and the instruments and the trocars are removed, the thoracic skin wounds are sutured.

Laparoscopic stage begins with patient positioning in dorsal decubitus in French position and insufflating of the peritoneal cavity with Veres needle and inserting the optical trocar and the supraombilical laparoscope. The position of the trocar during the laparoscopic procedure is the following: 10 mm optical trocar superumbilical on the xifo-umbilical line; 10-mm working trocar, subxiphoid for EndoFan endoscopic retractor; 10 cm trocar, supraombilical in the right upper quadrant on the right medial-clavicle line; 10 cm trocar, supraombilical to the left of the left medial-clavicle line; a 5 mm trocar in the left upper quadrant for inserting instruments used for traction and contertraction. After insertion of the trocars, the entire peritoneal cavity is explored, carefully to detect other pathologies or metastatic deposits, especially when the tumor is located in the distal esophagus. Place the patient in the Fowler position and incise the small omentum, then dissect the abdominal esophagus and the right diaphragm pillar using the Ligasure brush. The gastro-intestinal ligament is dissected, beginning in the middle and continuing with the gastro-splenic, gastro-frenous ligament. The dissection of the left pillar and the eso-gastric junction is performed and the left gastric pedicle is identified. After, it is cut to the right of the gastro-colic ligament with the gastro-epiploic arcade up to the antro-piloric region. Laparoscopic gastric mobilization is continued by sectioning of the coronary pedicle with a vascular stapler and performing the perigastric lymphadenectomy with the preservation of of the right gastro-pedicle as vascular suply for the gastric conduit.

Figure 15. Position of the trocars during laparoscopic stage (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 16. Section of hepato-gastric ligament (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 17. Section of gastro-colic ligament (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 18. Dissection of posterior gastric adhesions (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 19. Perigastric lymphadenectomy (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 20. Section of coronar pedicle (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 21. Partial section of the hiatus (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

The cervical stage follows and an incision is made at the anterior margin of the left sterno-cleidomastoid muscle, dissecting medio-vascularly to the carotid artery posteriorly to the prevertebral fascia. The cervical esophagus is isolated and is sectioned above the jugular incision of the sternum. For middle and superior tumors, we mobilize the entire stomach after the Nakayama technique, and for the inferior and eso-gastric tumors we resect the small curvature and practiced a gastric pull-up with a tubular stomach following the Akiyama technique.

The thoracic esophagus along with the future gastric cavity ascends through the posterior mediastinum via the esophageal bed in the cervical region under direct visual laparoscopic control and extracts through the left latero-cervical incision. The cardiac section is performed with a linear GIA or EndoGIA stapler with a blue cartridge after anchoring it with some reference threads and securing it to the cervical level. After cutting and closing the cardia with a linear stapler, the eso-gastric cervical anastosis end-to-side is performed in monolayer between the cervical esophagus and the fornix level with monofilament suture PDO 3-0.

Figure 22. Gastric conduit ascensioned through hiatus (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

The cervical wound is sutured and we returned to the abdominal cavity where a feeding jejunostomy using a Foley 28Ch catheter is used continuously mounted, exteriorized in the left upper quadrant and fixed with 3-0 silk threads to the parietal peritoneum. For laparoscopic jejunostomy, we use the trocar incision on the left medioclavicular line. Also, it can be mounted in the classic manner, a mini-laparotomy allows for a sufficient approach. After anchoring the first jejunal loop to the peritoneum on anterio abdominal wall, behind the trocar hole, we made a purse string using 3-0 Silk. The intestinal wall is opened using a Hook and the Foley catheter is inserted in the jejunum through the mentioned trocar. We check the position of the probe at the level of the jejunum both visually and by instillation of physiological serum. The jejunal loop is additionally anchored in several points to the anterior abdominal wall and the trocar is extracted and the jejunostomy is fixed to the skin as well. The practice of a piloroplasty as extra-mucosal myomectomy is often optional, while fitting a feeding jejunostomy to facilitate enteral nutrition during the postoperative period is the rule. We practice lavage of the peritoneal cavity with betadinate serum and its drainage at the diaphragmatic hiatus, with a drain tube exteriorized by the working trocar plaque on the right medoclavicular line. The wounds of the work trocars are sutured after their removal under direct vision.

Figure 23. Extraction of the esophagus specimen (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 24. Section of cardia (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 25. Preparing end-to-side cervical anastomosis -distal cervical esophagus and the gastric fornix (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 26. Eso-gastric end-to-side cervical anastomosis – final aspect (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 27. Laparoscopic assisted feeding jejunostomy (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 28. Subhepatic abdominal drainage (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

The communication between surgical team and anesthesia to prevent accidents that can lead to conversion to classical surgery is very important aspect of intraoperative management. Also, to prevent postoperative lung complications, the anesthetist uses a lung protection strategy during the intraoperative fluid-restricting operation of GDFT (gold directed fluid therapy), while maintaining hemodynamic stability not to affect the viability of the gastric graft [8].

Results

The total effective time was in the thoracoscopic approach 120 minutes, abdominal 130 minutes, cervical 50 minutes, total 300 minutes. The blood loss associated with the procedure was 200ml. The postoperative evolution was favorable, the patient was extubated at the end of the surgery, a pulmonary control radiograph was performed to assess the position of the drainage tubes after pulmonary expansion and was transferred to the ATI section for 48 hours. The patient followed an integrated post-esophagectomy care protocol that included intensive physiotherapy, early bed mobilisation and early enteral nutrition in the Z1 po on the feeding jejunostomy. Nasogastric tube is maintained in the early postoperative days for gastric drainage. On the 6th postoperative day, a digestive transit with iodate constrast substance was performed which revealed a high esogastric anastomosis with normal appearance without fistulas and a delayed emptying of the gastric conduit. In the 8th postoperative day the digestive transit of barium sulphate was repeated, which revealed a normal postoperative appearance without leakeage with the slow emptying of the stomach gastric at 5 minutes postingestional. The patient was discharged on postoperative day 10 without subjective symptoms with care recommendations of feeding jejunostom and the plan to return for a follow up at 3 weeks postoperatively. At the 30-day clinical and paraclinical re-evaluation, the feeding jejunostomy was extracted after a preliminary swallowing control, and at 90 days postoperatively there were no long term complications.

Figure 29. Postoperative aspect day 1 (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 30. Subtotal esophagectomy specimen (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

The final histology result reveals the ulcerated, invasive to the muscles of the ulcer, invasive to muscularis propria at 31 mm from the distal limit, the proximal limit without tumor infiltration with angio-limfo-neuroinvasia present – pT2pN0Mo. Perisophagian (thoracic) – 15 reactive lymph nodes and 23 periesophagian lymph nodes and left gastric (abdominal) – reactive.

Figure 31. Microscopic view. Hematoxilin eosine stain x20, (Leica ICC 50 HD) The green arrow – the keratin pearl characteristic of the keratinized squamous cell carcinoma. Yellow patch – non-keratinized squamous epithelium with cyto-arrhythmic disruption with tachycardic nuclei and nucleotide cytoplasmic ratio with ½ inferior epithelium (low-grade intraepilelic neoplasia). Blue arrow- cytaro-arrhythmic dissection with polar loss and cyto-nuclear ratio in favor of the nucleus throughout the thickness of the epithelium (high-grade intraepithelial neoplasia) Double arrow- in the surface, substance-free ulceration and fibrinoleucocyte exudate (collection of the Center of Excellence in Esophageal Surgery, St. Maria Clinical Hospital, Bucharest)

Figure 32. The 30-days postoperative aspect (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 33. Barium swallow 30-days postoperative (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Figure 34. CT TAP 90-days postoperative – transversal view (collection of the Center of Excellence in Esophageal Surgery, Sf. Maria Clinical Hospital, Bucharest)

Discussions

Although recently increased the incidence of esophagectomy using double thoracic and abdominal Ivor Lewis approach in current practice with increasing incidence of inferior esophageal and esophageal junction adenocarcinoma, the thoracoscopically, laparoscopically and cervical modified McKeown approach remains the choice for thoracic esophageal tumors because allows for extended mediastinal lymphoma.

Currently, in the selection of cases: age, body mass index, non-adjuvant RCT does not affect the decision for MIE. Given that we are in the curve of learning this type of minimally invasive approach, in this patient we used the left lateral decubitus to intervene and perform an emergency thoracotomy in the event of an accident during surgery. Also, the extracorporeal preparation of the gastric conduit that we practiced at the first esophagectomy through minimally invasive approach reduces the risks associated with the learning curve and has a positive impact on postoperative outcomes.

Performing the piloroplasty on vagotomized stomach is not absolutely necessary and we do not recommend it routinely, usually the slow discharge of the graft is resumed in the first few weeks postoperatively [9]. To control pain in the immediate postoperative period, we use high epidural anesthesia that facilitates post-operative extubation and early mobilization reduces the rate of respiratory complications, duration of hospitalization, and improves patient quality of life [10].

We support active respiratory physiotherapy and start early feeding on the jejunostomy well on the first day after surgery that is well tolerated in our experience. The changes of consciousness and infectious risk are carefully assessed by repeating laboratory tests and pulmonary x-rays to identify possible postoperative medical or surgical complications [11].

Regarding the use of two-dimensional image (2D) for minimally invasive esophagectomy, this is known for its limitations, such as difficult coordination of eyes and hands. Though the 3D thoracoscopic and laparoscopic HD approach, mainly due to the depth and detailed perception perception, is promising and appears to be superior to 2D in laparoscopic gastric mobilization, gastric tube formation, anastomosis and precise mediastinal lymphadenectomy, which could involve a improvement of clinical outcomes and remote postoperative outcomes of the patient, subsequent evaluation with randomized controlled trials should be performed prior to extrapolation of such a conclusion [12].

Image augmentation in the operator field and the use of a 3D High Definition video camera provides an excellent visual field to accurately pinpoint dissection plans and overcome difficult moments by reducing the risk of intraoperative incidents and accidents, and also enables an extensive periesophageal and perigastric lymphadenectomy facilitating a better staging.

Simplifying postoperative care and reducing the incidence of postoperative complications, especially pulmonary infections, results in a shorter duration of hospitalization and allows faster social reintegration [13].

The long learning curve of minimally invasive esophagectomy is much easier to overcome in the presence of an experience in classical surgery and advanced technical skills in minimally invasive surgery and the supervision of a mentor is mandatory for the first operations [14].

Difficulties encountered at certain operative stages, such as the presence of intrathoracic or intraperitoneal adhesions with prolonged incidence of surgical incidents or intraoperative accidents, can determine the conversion to open surgery. The literature reports an average conversion rate of 5-7% [15].

The advantages of the minimally invasive technique are evident in the immediate postoperative period, but also at a distance, oncological results are comparable to those of classical esophagectomy, proven by comparative studies on large cohort of patients operated, and randomized clinical trials such as TIME, MIRO or ROBOT who compared the results of classical surgery with those of the minimally invasive approach started in 2012 that have recently published oncological results at a distance [16-22]. It remains to be demonstrated as the accumulation of minimally invasive cases in our clinic decreases the incidence of local recurrences.

Conclusions

Advanced technology and optics of endoscopic surgery allow for better estimation of anatomical plans, access to narrow spaces, and therefore a more precise dissection with lower trauma in esophageal cancer surgery.

The long term outcomes of surgical treatment of esophageal cancer are an additional motivation for treatment orientation in order to obtain good results in patients' quality of life in the first postoperative year, results in which minimally invasive technique is surpassing open technique.

Modern Upper Gastro-intestinal surgeon should offer to the patients the opportunity to benefit from the minimally invasive approach and he should perform an esophagectomy with low rates of morbidity and mortality.

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