Surgery: Transthoracic Esophagectomy

Surgery has long been used to achieve locoregional control and has played a central role in the treatment of esophageal cancer. Curative resection of the primary lesion requires not only removal of the gross tumor but also eradication of potential microscopic spread of carcinoma. Thoracic esophageal carcinoma is frequently associated with extensive lymph node metastasis involving the cervical, thoracic, and abdominal regions. Because adequate mediastinal lymphadenectomy is essential, right transthoracic esophagectomy with mediastinal lymph node dissection and total resection of the thoracoabdominal esophagus has traditionally been performed. Transthoracic esophagectomy is one of the most invasive procedures in gastrointestinal surgery. Although morbidity and mortality associated with esophagectomy have markedly decreased over recent decades, they remain relatively high. Continuous advances in preoperative risk assessment, refinement of surgical techniques, and improvements in perioperative management are therefore required. Minimal invasive esophagectomy, including thoracoscopy-assisted esophagectomy and robot-assisted approaches, has been reported as a promising surgical option owing to its minimal invasiveness, improved cosmetic outcomes, reduced postoperative pain, lower incidence of respiratory complications, acceptable oncological radicality, and favorable long-term outcomes. However, the safety of minimally invasive esophagetomy has not yet been established for locally advanced esophageal cancer with suspected invasion of adjacent vital structures, such as the aorta, trachea, lung, or pericardium. In addition, with recent advances in systemic chemotherapy and radiotherapy, an increasing number of patients with initially unresectable advanced esophageal cancer are being considered for conversion surgery or salvage surgery following favorable treatment responses. In these complex and technically demanding cases, open transthoracic esophagectomy remains the preferred surgical approach at many institutions.