Esophagectomy followed by reconstruction for esophageal cancer is a highly invasive surgery known to have a high incidence of postoperative complications (PCs) 1-4. In recent years, minimally invasive esophagectomy (MIE), including robot-assisted MIE, has become widespread 2, 4, 5, and there has been an increase in esophagectomy following neoadjuvant chemotherapy (NAC) for advanced cancer 3, 5. Furthermore, the increase in esophagogastric junction cancers has led to an increase in the cases for which MIE using Ivor Lewis approach is indicated 4. In this context, a global challenge is how to safely promote MIE, particularly Ivor Lewis-type MIE to esophageal cancer patients after NAC, to improve prognosis. To compare the treatment outcomes of the new surgical technique, MIE, with the conventional open esophagectomy (OE), a multicenter randomized controlled trial (RCT) would be the most scientifically sound way. Recently, the non-inferiority in survival of thoracoscopic esophagectomy compared to OE has been scientifically proven by a prospective RCT in Japan 2. However, such clinical trials may be conducted in high-volume centers, with carefully selected patients and sometimes even limited surgeons. Therefore, it may be sometimes difficult to apply the novel findings to the real world universally at any facility. The results of RCTs should be introduced carefully to real world clinical practice with this important concern in mind. Desmond and colleagues have retrospectively analyzed and explored the postoperative outcomes of Ivor Lewis-type OE and hybrid/total MIE in the Australian and Aotearoa New Zealand (ANZ) cohort from 22 centers 5. Their study demonstrates that, from OE to total MIE, there was a stepwise decrease in the rate of major PCs regardless of the hospital case volume 5. This multicenter study yielded excellent results in enabling the relatively safe and widespread introduction of Ivor Lewis-type MIE in the ANZ region. It also suggests that a certain level of safety could be maintained even in low/moderate-volume centers, and furthermore, esophageal surgeons in the ANZ region possess sufficient knowledge and surgical skills. However, centers performing ≥ 12 esophagectomies per year tended to have fewer PCs compared to lower-volume centers in both OE and MIE 5, suggesting the significance for esophageal surgery, regardless of the approach, to be delivered in centralized cervices. This ANZ study failed to demonstrate that long-term survival rates of hybrid/total MIE were superior to that of OE 5, whereas MIE, with its better short-term postoperative outcomes than OE, was expected to have a better long-term survival than OE as well. The authors have speculated that this may be due to the influence of preoperative FLOT therapy. A recent report of an exploratory analysis of phase III RCT in Japan has revealed that intensified NAC (doublet cisplatin plus 5-fluorouracil or triplet docetaxel plus cisplatin plus 5-fluorouracil) and MIE may reduce the negative prognostic impact of PCs after esophagectomy 3. However, in the retrospective ANZ study, the surgical procedure was limited to Ivor Lewis-type esophagectomy, and the NAC regimen differed from the Japanese study. It remains unclear whether the impact of preoperative FLOT therapy on long-term prognosis differed depending on the surgical approach. Therefore, a direct comparison with the Japanese study results is not feasible. It may be possible that, in the ANZ study, the slightly lower number of harvested lymph nodes in MIE may be associated with no survival advantage over OE. The Japan Esophageal Society (JES) has a system for certification of qualified surgeons as “Board Certified Esophageal Surgeons” (BCESs), including both of the authors, and institutes as “Authorized Institutes for Board Certified Esophageal Surgeons” (AIBCESs) in which BCESs participate in surgery. As a result, the long-term survival of esophageal cancer patients who underwent surgery at AIBCESs was significantly better than that at non-AIBCESs 1. Establishing national or regional systems to standardize the surgical skills of esophageal surgeons would be effective in safely promoting MIE that ensures the quality of cancer surgery. Because the ultimate goal of a novel cancer treatment is to improve long-term prognosis, we await further consideration of what needs to be done to ensure that MIE offers a better prognosis than OE during the NAC era. To achieve improved long-term survival, institutes performing esophageal cancer surgery are expected to have early diagnosis of PCs in addition to having a low incidence of PCs, well-established emergency and interventional radiology systems, and consequently, few cases of failure to rescue (FTR). Although the treatment volume must be important for effective management of PCs, multidisciplinary team medicine including nutritional care is also crucial. On the other hand, advanced age and cardiac comorbidities, as patient-side clinical risk factors, have reportedly been associated with FTR after Ivor Lewis-type MIE 4. Whereas regional differences need to be taken into consideration, it will be mandatory to accurately assess patient risk and select the appropriate hospital based on the case. When considering MIE for high-risk patients, the authorized institutes such as Japanese AIBCESs (usually high-volume centers) should take the lead. It will be an important future challenge for safely providing highly complex MIE to high-risk esophageal cancer patients. Ultimately, Desmond and colleagues make a valuable contribution to our consideration of the current situation and future challenges of esophageal cancer surgical treatment in the real world: The safe dissemination of MIE tailored to regional circumstances and the selection of appropriate cases at each facility will be necessary for improving outcomes of esophageal cancer treatment in the modern era of NAC followed by MIE. Yoshihiro Nabeya: conceptualization, writing – original draft, writing – review and editing. Kiyohiko Shuto: supervision, writing – review and editing. The authors have nothing to report. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
Nabeya et al. (Sun,) studied this question.