title: Early experience and lessons learned in a new minimally invasive esophagectomy program.
abstract: BACKGROUND
  Minimally invasive esophagectomy (MIE) is gaining increasing popularity in the treatment of esophageal cancer. In fact, while surgical and oncologic outcomes are not inferior to those achieved through a traditional open approach, patients undergoing MIE benefit from shorter length of stay, lesser pain and prompter recovery. This technique is, however, highly challenging, and the development of a MIE program, even in the setting of a tertiary center, requires time and progressive honing of surgical skills.
  
  
  METHODS
  We use a minimally invasive Ivor Lewis approach. The abdominal phase of the procedure includes complete celiac lymphadenectomy and tubularization of the stomach, which will constitute the neo-esophagus. The video-assisted thoracoscopic surgery portion of the operation takes place in left lateral decubitus and allows for optimal thoracic lymphadenectomy and anastomosis.
  
  
  RESULTS
  From October 2011 to January 2015, we treated 52 patients with the above-described procedure. The evolution of our anastomotic technique included a first group of circular stapled anastomosis with Orvil™ and 3.5-mm EEA™ (n = 16 patients), subsequently abandoned in favor of a linear anastomosis (n = 12), before going back to the Orvil™ coupled with 4.8-mm EEA™ (n = 22) in more recent times. There were also an additional two anastomoses that did not fall under any of these categories. We experienced two postoperative deaths. The overall leak rate was 14%, but fell down to 4% in the last group. Median LOS was 9 days. Lymph node retrieval was adequate throughout the whole series.
  
  
  CONCLUSIONS
  Developing a MIE program requires a significant learning curve before the results plateau. Only once a technique of choice is refined and mastered, the advantages granted by MIE become apparent.
authors.affiliation: Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Blalock 240, Baltimore, MD, 21287, USA.
authors.forename: Benedetto
authors.initials: B
authors.lastname: Mungo
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Anne O
authors.initials: AO
authors.lastname: Lidor
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Miloslawa
authors.initials: M
authors.lastname: Stem
authors.affiliation: Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Blalock 240, Baltimore, MD, 21287, USA. dmolena2@jhmi.edu.
authors.forename: Daniela
authors.initials: D
authors.lastname: Molena
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical / Q000009:adverse effects / Q000379:methods*; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D013270:Stomach / Q000601:surgery; D020775:Thoracic Surgery, Video-Assisted / Q000009:adverse effects / Q000379:methods*
keywords: Barrett’s esophagus; Esophageal cancer; Esophagectomy; Laparoscopy; Thoracoscopy