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Hasson et al. Mini-invasive Surg 2020;4:46 I http://dx.doi.org/10.20517/2574-1225.2020.10 Page 3 of 16

Figure 1. Torek Esophagectomy. Franz Torek first described resection of the thoracic esophagus using a rubber tube. Used with
permission: The Annals of Thoracic Surgery 1965;4(85):1497-1499.

RESULTS
History of esophagectomy and open techniques
To better understand advancements in esophageal surgery, it is important to take a moment to review
the history of esophageal resection and the complexities of this procedure. Ivor Lewis said it best when
he stated, “there is little doubt that the successful outcome of curative surgery for esophageal carcinoma
remains one of the great challenges of surgical practice”. Historically, innovation drove many advancements
in treatment of esophageal disease dating back to 1913. Franz Torek first described resection of the thoracic
esophagus using a rubber tube to create an extra-anatomic reconstruction [Figure 1] [8,13] .

Amazingly, the patient survived for 13 years, leading to the evolution of surgical procedures to resect the
[14]
esophagus and replace it with a gastric conduit . Subsequent versions have included the Ivor Lewis (IL)
[15]
esophagectomy via right or left thoracotomy with subsequent two-field esophagectomy ; the McKeown
esophagectomy involving a three-field esophagectomy with thoracotomy and laparotomy and terminating
[16]
with a cervical anastomosis ; and Orringer and Sloan’s transhiatal esophagectomy (THE), involving
[17]
laparotomy and cervical anastomosis .
The Achilles heel of esophageal cancer surgery has always been the high complication rates, even
when performed at high-volume centers. Despite improvements over the years, the rates of morbidity
and mortality of open esophagectomy remain high and are estimated to range 30%-60% and 5%-10%,
[8]
respectively, depending on patient comorbidities and place of operation . Mortality has been shown to
[8]
decrease to < 5% in centers that perform more than 100 esophagectomies per year . Although technical
advances have improved the rate of anastomotic leak, consequences of a leak into the chest were and
[18]
continue to be devastating and difficult to manage . Notably, transhiatal esophagectomy has historically
demonstrated reduced mortality rates from anastomotic leak resulting in less severe consequences
compared to the IL approach, although it does have a higher overall leak rate. Meta-analysis has further
demonstrated a mortality rate of 6.3% for transhiatal esophagectomy compared with 9.5% for the IL