ROBOT ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Esophageal cancer is the 8th most common malignancy and the 6th leading cause of cancer-related mortality worldwide with more than 450.000 new cases and 400.000 esophageal cancer related deaths. Esophageal cancer is therefore one of the most aggressive and fatal cancers with an overall 5-survival rate of 15-25%. There are two major histological types of esophageal cancer: esophageal squamous cell carcinoma (SCC) usually occurring in the middle or proximal one-third of the esophagus and esophageal adenocarcinoma (AC) usually occurring in the lower one-third or gastro-esophageal junction. Following neoadjuvant treatment, resection of the esophagus with en-bloc lymphadenectomy is the cornerstone of curative treatment for patients with locally advanced esophageal cancer. A transthoracic esophagectomy with two-field lymph node dissection and gastric conduit reconstruction is worldwide the preferred procedure for resection of esophageal cancer. However, the percentage of cardiopulmonary complications associated with this procedure is high (50-70%). In recent year, a lot of progress was made to decrease the percentage of complications and death and to improve survival after esophagectomy, but many challenges remain to improve outcome. The aim of the research in this thesis was to improve survival after esophagectomy and to reduce complications. A strategy to improve survival is to add perioperative chemotherapy or neoadjuvant chemoradiotherapy to the treatment of esophageal cancer. In part I of this thesis, perioperative chemotherapy and neoadjuvant chemoradiotherapy are compared to evaluate which therapeutic regimen is superior for patients with esophageal adenocarcinoma. Robot assisted minimally invasive esophagectomy (MIE) was developed to improve the postoperative mortality and morbidity by reducing the surgical trauma compared to an open operation. A reducution in postoperative complications might also results in a faster postoperative recovery. In part II of this thesis, all aspects of robot assisted minimally invasive esophagectomy were evaluated. In part III of this thesis, different techniques for restoring continuity with a gastric conduit were compared, a scoring system for postoperative pneumonia was proposed and a new operation technique for recurrent esophageal carcinoma was described.