Esophageal cancers usually present to us in advanced stages. For locally advanced respectable cancer of the esophagus, current evidence favors a multi-modality approach. The treatment associated with the best long-term survival outcomes for this stage is a combination of chemotherapy and radiotherapy followed by surgery.
The surgery for esophageal cancer can be performed by various approaches. Popular amongst these are trans-hiatal and trans-thoracic approaches. The advantage of a trans-thoracic over a trans-hiatal approach is that it leads a to better lymph node dissection and the tumor is removed under vision, thus avoiding any blind dissection. This leads to an optimal staging and an improvement in survival. However, the biggest drawback of a conventional trans-thoracic approach is that it requires a thoracotomy and thus an added morbidity and risk of pulmonary complications.
Video-assisted thoracoscopic surgery, especially due to avoidance of a thoracotomy, has led to an improvement in postoperative outcomes resulting in lesser complications and faster recovery. However, surgery for esophageal cancer is a major procedure and should only be performed by surgeons with requisite expertise. Below mentioned are 2 cases of locally advanced resectable cancer of the esophagus treated with VATS esophagectomy after preoperative therapy.

67 year gentleman, a known diabetic, was diagnosed with a locally advanced adenocarcinoma of lower third of esophagus (cT3N1). He was treated with neoadjuvant chemoradiation followed by surgery. He underwent Video-Assisted Thoracoscopy Surgery (VATS) esophagectomy. The thoracic part of the procedure was done through 3 small cuts and the abdominal part through a larger incision. The anastomosis is then performed in the neck. The postoperative course was uneventful. Histopathology report showed a complete (R0) resection, ypT3N1 (1/22 lymph nodes).

58 year lady, a known case of hypothyroidism, was diagnosed with a locally advanced squamous cell carcinoma of middle one-third of the esophagus (cT3N0). She was treated with neoadjuvant chemoradiation followed by surgery. Video-Assisted Thoracoscopic Surgery (VATS) esophagectomy was performed. The postoperative course was uneventful. Histopathology report showed a complete pathological response i.e. no residual tumor (0/24 lymph nodes). This kind of a response to chemoradiation can be expected in approximately 20-40% of patients depending of the initial stage and histological subtype. Patients with a complete pathological response are associated excellent survival outcomes.

Figure shows the well healed incisions following VATS esophagectomy (a) left neck (b) thoracoscopic port sites (c) abdominal. A well healed anastomosis is demonstrated on postoperative contrast study (d).