Selected Commentary to "Fifty-five minimally invasive esophagectomies: a single center experience"

Comparison of ventilation and cardiovascular parameters between prone thoracoscopic and Ivor Lewis esophagectomy

Thoracoscopic esophagectomy in the prone position is associated with better surgical ergonomics compared to the left lateral decubitus position due to the effects of gravity pooling blood outside the operative field and the reduced need for lung retraction. The aim of this study was to evaluate the physiological effects of prone thoracoscopic esophagectomy with single-lumen intubation on ventilation, respiratory gas exchange, and cardiovascular parameters. Thirty-two consecutive patients underwent esophagectomy either through a prone thoracoscopic approach or through a right thoracotomic approach. Samples of arterial and central venous blood, as well as ventilation and cardiovascular parameters were obtained at baseline, during induction of anesthesia, throughout the operation, and after extubation. Patients undergoing prone thoracoscopic esophagectomy showed higher oxygenation levels (p < 0.001), and a significantly lower mean pulmonary shunt fraction (p = 0.001). Perioperative hemodynamics remained stable throughout the surgical procedures. Thoracoscopic esophagectomy in the prone position with two-lung ventilation was associated with a significant improvement of global oxygen delivery and a significant reduction of the pulmonary shunt when compared to the Ivor Lewis operation.

Curative treatment of oesophageal carcinoma: current options and future developments

Since the 1980s major advances in surgery, radiotherapy and chemotherapy have established multimodal approaches as curative treatment options for oesophageal cancer. In addition the introduction of functional imaging modalities such as PET-CT created new opportunities for a more adequate patient selection and therapy response assessment.

The majority of oesophageal carcinomas are represented by two histologies: squamous cell carcinoma and adenocarcinoma. In recent years an epidemiological shift towards the latter was observed. From a surgical point of view, adenocarcinomas, which are usually located in the distal third of the oesophagus, may be treated with a transhiatal resection, whereas squamous cell carcinomas, which are typically found in the middle and the upper third, require a transthoracic approach. Since overall survival after surgery alone is poor, multimodality approaches have been developed. At least for patients with locally advanced tumors, surgery alone can no longer be advocated as routine treatment. Nowadays, scientific interest is focused on tumor response to induction radiochemotherapy. A neoadjuvant approach includes the early and accurate assessment of clinical response, optimally performed by repeated PET-CT imaging and endoscopic ultrasound, which may permit early adaption of the therapeutic concept. Patients with SCC that show clinical response by PET CT are considered to have a better prognosis, regardless of whether surgery will be performed or not. In non-responding patients salvage surgery improves survival, especially if complete resection is achieved.