neoadjuvant treatment for locally advanced esophageal cancer is the standard of care [ 1 , 2 ] . previously , it was considered that transthoracic esophagectomy is the standard of care for oncological resection , but orringer challenged this claim in the 1970s and redescribed the transhiatal procedure as equally effective but less morbid than transthoracic procedure owing to less postoperative pulmonary complications . with the advent of laparoscopes , it is a complex procedure requiring greater operative time , but it is associated with shorter hospital stay and lesser blood transfusion requirements [ 58 ] . at our institution since 2011 , we have started performing minimally invasive esophagectomy , with thoracic part of the procedure being performed by a thoracic surgeon . there are no studies from pakistan reporting initial experience of morbidity and mortality for mie . we decided to look into our experience of mie to report morbidity and mortality with this procedure , during initial 51 cases . we hope that this experience will help other institutes from developing world to identify what to expect when starting with new mie . this is a review of morbidity and mortality for first 51 mie procedures for locally advanced esophageal cancer , that were resectable , on post neoadjuvant computerized tomography ( ct ) of chest and abdomen . all patients undergoing mie at shaukat khanum memorial cancer hospital , for resectable esophageal cancers between january 2011 and may 2013 , were reviewed . pretreatment upper gi endoscopy , endoscopic ultrasound ( eus ) , and ct chest and abdomen with iv contrast were performed to clinically stage the disease . patients with locally advanced disease ( patients with t3 or above and/or n1 disease ) require neoadjuvant chemoradiotherapy prior to surgical intervention . patients received external beam radiation between 45 and 55  gy with concurrent cisplatin and 5fu . vats part of the procedure was performed by a thoracic surgeon , while abdominal and cervical part was performed by two surgeons . record was kept for any intraoperative complication as well as postoperative wound infection , anastomotic leak , chyle leak , postoperative collections and any respiratory or cardiac problems requiring second intervention or prolonged stay in icu and hospital . ( occurring after 30 postoperative days ) , record was kept for significant aspiration causing repeated emergency room visits or admissions , anastomotic narrowing requiring dilatation or stent placement , and delayed gastric emptying requiring motility enhancing agents . patients were reviewed 10 days after discharge and then at the end of the first month and quarterly for 2 years . on each visit , patients undergo history and physical examination with any significant complaint of dysphagia to solids prompting endoscopy for evaluation of anastomosis and any suspicious area , biopsied . for patients with palpable cervical nodes or other significant clinical findings , a ct scan of that area would be required to exclude metastatic disease . in case of nonsignificant issues , patients were placed in left lateral position and vats was performed by a thoracic surgeon using 4 ports . once esophageal mobilization was complete from thoracic inlet till hiatus , patients were then changed to modified lithotomy position and abdominal part of the procedure was performed and stomach tube was created based on right gastric and right gastroepiploic vessels . cervical part of the procedure was then performed through a hockey shaped incision along left sternocleidomastoid . tube was then passed through posterior mediastinum to neck , where single layer hand sewn esophagogastric anastomosis was performed using interrupted sutures of prolene 4/0 . frequencies were calculated for descriptive statistics , while means were calculated for all continuous variables . overall survival was calculated from date of diagnosis to date of death or last follow - up . 17/51 ( 33.33% ) patients belong to stage ii while 34/51 ( 66.66% ) were stage iii on initial staging workup . all patients had r0 resection , and 1 patient in minimally invasive group was found to have disease at peg site on final histopathology . perioperative morbidity was in 16 ( 31.37% ) patients , as in table 2 . wound infection occurred in 3 ( 5.88% ) patients . out of these , 2 patients had superficial wound infection of peg site excision wound , while 1 had infection of vats wound . all patients were managed conservatively with placement of nasojejunal tube for feeding , which was later removed once contrast study at three weeks showed no leak and patient started tolerating oral diet . we encountered 2 chyle leaks , and both required thoracotomy and ligation of thoracic duct . reexploration was required in 3 ( 5.88% ) patients , 2 had chyle leak , while 1 had collection in mediastinum . most frequent long - term morbidity was anastomotic narrowing observed in 5 ( 9.88% ) patients . our mean overall survival was 37.66 months ( 95% confidence interval 33.75 to 41.56 months ) , as in figure 1 . mean disease - free survival was 24.43 months ( 95% ci 21.26 to 27.60 months ) , as in figure 2 . over the past decade many institutions had been performing minimally invasive esophagectomy as an alternative to open procedure and had shown it to be equally safe [ 912 ] . in our data , we had presented the outcomes of mie . these were the first 51 mie procedures being performed , so we had provided the perspective of how safe the procedure was when starting initially . had shown morbidity rate of 34.5% . in our experience 31.37% of patients undergoing mie suffered some morbidity . . only 1 participant of our mie group suffered hospital acquired pneumonia . in another study schopmann literature reports pulmonary morbidity around 22% , but definition of major and minor respiratory complications were not well defined . our better results were likely related to the consistent use of preoperative breathing exercises , postoperative thoracic epidural for pain control , and restarting early chest physiotherapy and incentive spirometry . three patients ( 5.88% ) required thoracotomy , one for mediastinal collection drainage and two for thoracic duct ligation . when looked at morbidity after 6 months , 11.6% patients suffered long - term morbidity . though we were expecting extra lymph node yield with mie , during the initial phase of our study thoracic duct was not taken as part of specimen and also subcarinal lymph nodes were not taken en block with esophagus . however with incorporation of the aforementioned steps , our lymph node yield increased to over 20 lymph nodes per resection . results for our hospital stay and icu stay have been skewed by 2 chyle leak patients as they both required longer hospital stay of 31 and 29 days . also , their icu stay was 21 days for the 1st patient and 16 days for the 2nd patient . we get our contrast study on the 6th day and the patients go home on the 8th day . limitations include small sample size . however , this is the first data about outcomes of mie from pakistan and we hope that it will encourage other institutions in developing nations to adopt this technique safely .
background . two common procedures for esophageal resection 
 are ivor lewis esophagectomy and transhiatal esophagectomy . 
 both procedures have high morbidity rates of 2046% . 
 minimally invasive esophagectomy has been introduced to decrease morbidity . 
 we report initial experience of mie to determine the morbidity and mortality associated with this procedure during learning phase . 
 material and methods . 
 patients undergoing mie at our institute from january 2011 to may 2013 were reviewed . 
 record was kept for any morbidity and mortality . 
 descriptive statistics were presented as frequencies and continuous variables were presented as median . 
 survival analysis was performed using kaplan meier curves . 
 results . 
 we performed 51 minimally invasive esophagectomies . 
 perioperative morbidity was in 16 ( 31.37% ) patients . 
 there were 3 ( 5.88% ) anastomotic leaks . 
 we encountered 1 respiratory complication . 
 reexploration was required in 3 ( 5.88% ) patients . 
 median operative time was 375 minutes . 
 median hospital stay was 10 days . 
 the most frequent long - term morbidity was anastomotic narrowing observed in 5 ( 9.88% ) patients . 
 there were no perioperative mortalities . 
 our mean overall survival was 37.66 months ( 95% confidence interval 33.75 to 41.56 months ) . 
 mean disease - free survival was 24.43 months ( 95% ci 21.26 to 27.60 months ) . conclusion . 
 minimally invasive esophagectomy , when performed in the learning phase , has acceptable morbidity and mortality .