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influencing the learning curve. Randomized controlled trials are necessary to confirm the good results obtained and
to give recommendations to avoid a high rate of complications during the learning curve for this difficult technique.

Keywords: Minimally invasive esophagectomy, Ivor Lewis, esophageal cancer, thoracoscopic esophagectomy

INTRODUCTION
Esophagectomy is a complex surgical procedure that requires two- or three-field access depending on tumor
location, histology, preoperative clinical staging, comorbidities, anatomy, and physiological status. Despite
considerable improvements in cancer staging, patient selection and surgical results in recent decades,
overall and pulmonary complication (PC) rates have remained high enough to encourage the search for
alternative operative techniques that could achieve similar cure rates with less morbidity and probable better
postoperative quality of life (QoL).

Many different techniques have been adopted worldwide to achieve complete tumor resection and appropriate
lymphadenectomy; a minimally invasive (MI) approach is used either for the abdominal or thoracic portion
of surgery time or for both . The Ivor-Lewis (IL) esophagectomy is the universally accepted technique to
[1,2]
resect cancers situated in the middle and distal esophagus and esophagogastric junction (EGJ).

A minimally invasive approach was considered elective by 14% of surgeons involved in a National survey on
treatment of esophageal and EGJ cancer in 2007; the same survey reported an increase to 43% of surgeons in
2014. This indicates a shift towards more diffuse application of this technique for such a complex operation.
It is also interesting to observe that the preferred site of the anastomosis for esophagogastroplasty has
changed from cervical to intrathoracic . The reason for this relevant interest in MI surgery is represented by
[3]
the possible reduction of PCs and length of hospital stay (LOS) related to this approach, without negatively
affecting the outcomes in terms of anastomotic leaks.

The application of laparoscopy and thoracoscopy to perform a totally MI Ivor-Lewis (TMIIL) esophagectomy
follows the idea to obtain further improved results in terms of postoperative complications and QoL.

The present work reviews our initial experience with this technique and compares the short-term outcomes
obtained in this group of patients with the results obtained in patients submitted to hybrid Ivor-Lewis (HIL).
Data of the current literature on TMIIL are also reported and discussed.

METHODS
Since 2005, our standardized approach for patients affected by cancer of the distal esophagus and EGJ has
been HIL, except in case of bulky tumors for which a relative contraindication was evidenced. From 2013
to 2016, few cases of highly selected patients were approached with TMIIL, in a stage 1 and 2a setting,
according to the IDEAL recommendations [Figure 1] .
[4-6]

From January 2017 to July 2018, in a stage 2b setting, all patients for whom the laparoscopic procedure lasted
less than 3 h, completed, as intention to treat, the thoracoscopic procedure.

The research was performed in accordance with the Declaration of Helsinki and all patients gave informed
consent to the procedure.

The results obtained in consecutive patients submitted to TMIIL and HIL between January 2017 and July
2018 were retrospectively analyzed. Data were collected in a prospective database.