Randomized controlled trial on minimally invasive versus open esophagectomy for esophageal cancer: short and long-term outcomes

The incidence of esophageal cancer has been increasing over the past two decades (1). Despite improvement in treatment options, such as chemotherapy and radiotherapy, esophagectomy with regional lymph node dissection remains the mainstay of curative modality for patients with localized thoracic esophageal cancer. Morbidity is a major concern during the follow-up period because of the invasive nature of esophagectomy and the complex operative procedures involved. Long thoracic and abdominal incisions and one-lung ventilation during esophagectomy are thought to be partly responsible for the high surgical invasiveness and subsequent respiratory complications of this procedure. On the other hand, a thoracoscopic approach, which could reduce the length of skin incision, has been attracting attention as a minimally invasive esophagectomy (MIE). By the late 1990s, several surgeons had performed and demonstrated the safety and feasibility of the technique (2,3). After these exploratory investigations, reports from large single-center studies began to reveal improvements in the surgical outcomes of MIE (4). Meta-analyses using individual institutional reports showed that compared with open esophagectomy (OE), MIE was associated with less operative blood loss, shorter length of intensive care unit and hospital stays, and reduced incidence of postoperative respiratory complications (5,6). On the other hand, results from several nationwide database analyses have been disappointing and demonstrated that MIE did not reduce postoperative respiratory complications and had higher reoperation or reintervention rates (7,8). However, these unexpected results of the nationwide database analyses may be attributable to the inclusion of a wide range of patients, surgeons, and hospitals. Therefore, we have recognized the necessity of a prospective study to determine the lower invasiveness and improved quality of life (QOL) associated with MIE, compared with OE.