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Minimally invasive esophagectomy with hybrid position can be a promising surgical procedure to achieve radical lymphadenectomy with less postoperative complication

© Annals of Laparoscopic and Endoscopic Surgery. All rights reserved. Ann Laparosc Endosc Surg 2020 | http://dx.doi.org/10.21037/ales-20-91 Esophageal cancer has been a dismal disease because it metastasizes even in the early stage, and it is the 8th leading cause of cancer death worldwide in 2018 (1-3). Multidisciplinary treatment consisting of surgery, chemotherapy, and radiotherapy helped to improve treatment outcomes (4,5). Since 2000, a number of landmark trials have been reported for surgically resectable esophageal cancer and preoperative chemo-/ chemoradiotherapy followed by surgery was established as a standard (6-8). More recently, the immune checkpoint inhibitors were reported to be beneficial for metastatic esophageal cancer (9), and it is about to be transferred to neoadjuvant setting (10). Although multidisciplinary treatment is vital, surgical resection has been a mainstay to cure esophageal cancer patients (11). Esophageal cancer has a widely spread lymphatic route and induces metastasis from the cervix to abdominal field especially in esophageal squamous cell carcinoma (ESCC) (1,2,12). Takeuchi et al. validated the sentinel lymph node (LN) mapping in cT1N0 ESCC and confirmed that esophageal cancer located at the middle thoracic esophagus has sentinel LN in cervical and abdominal field at higher than 10% (12-14). Udagawa et al. reviewed the distribution of LN metastasis and the efficacy for each LN station (15). To achieve radical lymphadenectomy, three-field LN dissection was reported to improve patient survival and has been conducted as a standard treatment (16-18). On the other hand, esophagectomy is highly invasive and highly morbid. Takeuchi et al. found that the operative morality was 3.4% using the Japanese nationwide registry data. Similarly to other cancer types, the postoperative complication was shown to negatively affect prognosis (19). Furthermore, we previously reported that the postoperative systemic inflammatory response induced by esophagectomy could induce cancer relapse and worsen the prognosis independent of postoperative complications (20). Therefore, establishing safe surgical procedure with less morbidity and mortality has been desirable. Minimally invasive esophagectomy (MIE) has been introduced in 1992 and has been widespread worldwide (21). Smaller incision and modification of lung mobilization decrease surgical stress. Biere et al. conducted a randomized control trial comparing MIE with open esophagectomy and found a significant reduction in pulmonary complication in MIE group (22). The Japanese nationwide registry data was consistent with the result (23). On the other hand, there are few studies comparing the long-term outcome between MIE and open surgery. The current phase III trial, JCOG 1409, will provide the answer to the remaining question (24). In the current era of MIE, the surgical approach could be a key component that affects the postoperative course. In terms of patient position during thoracic approach, the left lateral or prone position has been widely used. The hybrid position—prone and left lateral decubitus—was developed Editorial