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BJS, 2023, 110, 1116–1117

https://doi.org/10.1093/bjs/znad208
Advance Access Publication Date: 13 July 2023
Gloves Off – Debates

Benefits of maximally invasive oesophagectomy


Nick D. Maynard*

Department of Upper Gastrointestinal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK

*Correspondence to: Nick D. Maynard, Department of Upper Gastrointestinal Surgery, Surgery and Diagnostics Centre, Churchill Hospital, Old Road, Headington,
Oxford OX3 7LE, UK (e-mail: nick.maynard@nds.ox.ac.uk)

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Open or ‘maximally invasive’ oesophagectomy has been the recent decades. The centralization of specialist surgical services
standard for the surgical treatment of oesophageal cancer for in recognition of the volume–outcome relationship for
decades; in conjunction with perioperative chemotherapy or oesophagectomy, the multidisciplinary approach to the surgical
chemoradiotherapy, it offers the best chance of long-term cure management of these patients, the widespread adoption of
for locally advanced oesophageal carcinoma. Indeed, with enhanced recovery protocols, and detailed recording of
advances in systemic chemotherapy and radiotherapy, outcomes in audits and registries8,9 have all been major factors.
long-term cure rates of 50 per cent or more can realistically be These changes have arguably all been more important than the
achieved after multimodal treatment of oesophageal cancer developments in surgical approach, while not denying the
with surgical resection at the core1,2. benefits of standardization of appropriately radical oncological
There are many operative approaches to resecting and surgery.
reconstructing the oesophagus, and both patient- and As W. Edwards Deming, the leading quality management
tumour-related factors should be considered when deciding the thinker, said: ‘Without data you’re just another person with an
optimal approach. The location of the tumour and its opinion’. Regrettably, opinion rather than evidence has been the
relationship to adjacent organs, and the position of any main driver behind the choice of surgical approach for
resectable metastatic lymph nodes, all need to be considered, oesophagectomy; despite several decades of oesophagectomy
together with patient factors such as previous surgery, being a safe and standard practice, the debate about which
co-morbidities, and adverse physiology. Which oesophageal approach is best remains open. It appears that oncological
replacement conduit is used may determine the operative outcomes are equivalent for open and minimally invasive
approach, and the operation can be tailored not only to the approaches (both MIO and RAMIE). Although short-, medium-,
individual patient and their cancer, but also to the experience and long-term survival are similarly equivalent, quality-of-life
and expertise of the surgeon. (QoL) studies are showing improved QoL after MIO compared
The primary oncological aim of surgery is to perform a safe and with open oesophagectomy5. The potential benefits of MIO or
comprehensive en bloc R0 resection. Thus, the optimal surgical RAMIE are obvious to all, and instinctively all those involved in
approach must allow wide circumferential resection of the the treatment of patients with oesophageal cancer foresee the
primary tumour with an appropriate margin of perioesophageal minimally invasive approach (whether MIO or RAMIE) becoming
tissue to maximize the chance of achieving negative resection the standard of care for surgical treatment of oesophageal
margins, and access for an appropriately radical nodal cancer. Indeed, the routine use of MIO (and now RAMIE) has
dissection. The most popular approach for many years has been increased worldwide over the past decade, with over 50 per cent
the Ivor Lewis oesophagectomy, involving a laparotomy and of oesophagectomies being performed using minimally invasive
posterolateral right thoracotomy; this can be combined with a approaches8. There remains, however, a lack of robust evidence
cervical incision in a three-stage or McKeown oesophagectomy. as to which minimally invasive approach is best, and it may be
A left thoracoabdominal approach3,4 has particular benefits for that patient demand and market forces will be the main drivers
bulky lower-third and junctional cancers, and, although behind adoption of advanced minimally invasive approaches
oncologically questionable, a transhiatal approach is still such as RAMIE rather than improved patient outcomes.
occasionally appropriate. Does this mean, however, that the open approach will become
In the past decade there has been an explosive, and largely obsolete? Is there still a role for ‘maximally invasive
uncontrolled, increase in use of the minimally invasive surgical oesophagectomy’? The answer, surely, must be yes; not only
approach to resection of the oesophagus, either totally will there be patient and tumour factors which may determine
minimally invasive (minimally invasive oesophagectomy, MIO), that an open approach is better, there will also be surgeon
or a hybrid approach combining laparoscopy with thoracotomy factors. Despite the obvious potential advantages of the
or laparotomy with thoracoscopy5,6. More recently, advanced minimally invasive approach, in the latest National
surgical optics and technological innovation in the control of Oesophago-Gastric Cancer Audit Report (2022)10, only 18.4 per
surgical instruments have led to the introduction of cent of oesophagectomies in England and Wales were carried
robot-assisted minimally invasive esophagectomy (RAMIE)7. out via a full minimally invasive approach. The surgery can be
There have been many changes to surgical services that have extremely challenging owing to both the proximity of the
contributed to the improved outcome from oesophagectomy in airways, heart, and great vessels, and the rigidity of the surgical

Received: April 30, 2023. Accepted: May 18, 2023


© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please e-mail:
journals.permissions@oup.com
Maynard | 1117

instruments with no angulation. Not all surgeons necessarily Data availability


have the high levels of surgical skill demanded by this surgery,
There are no new data in this manuscript.
and, perhaps more importantly, they may not have the
appropriate comfort level to do this surgery with confidence.
Much of this can be mitigated of course by the adoption of
robotic surgery, but the learning curves for both MIO and RAMIE
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The author declares no conflict of interest. V1.1.pdf (accessed June 2023)

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