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Esophageal cancer is the sixth most common cause of cancer-related death. Choice of surgical approach and individualized treatment is crucial. The aims of this thesis were to evaluate the introduction of minimally invasive esophagectomy (MIE) regarding oncological results and postoperative complications. To investigate radiological differences in pulmonary complications between MIE and open technique by studying computed tomography (CT). To evaluate geographical differences in intention for curative treatment and their association to survival. As well as to further explore these differences by comparing assessments of tumor stage (TNM) and treatment recommendations in anonymized cases at regional multidisciplinary cancer conferences (MCC).

A comparison of 51 MIE (21 hybrid and 30 totally minimally invasive) and 65 open resections in 2007-2016, showed an increased lymph node yield in the MIE group, 18 (13–23) vs. 12 (8–16) median (IQR), p<0.001. The result was confirmed in a multivariate regression model (adjusted odds ratio 3.15 [1.11–8.98], p=0.03). Postoperative complications did not differ between the groups.

When comparing CT after open esophagectomy (n=20) and MIE (n=20), no ipsilateral differences in the areas of atelectasis or pleural effusion were seen. Nor did the groups differ in the proportion of patients with clinically important atelectasis (dx: 30% vs. 25%, sin: 65% vs. 65%) or pleural effusion (dx: 15% vs. 15%, sin: 65% vs. 45%).

A total of 5959 esophageal cancer patients, diagnosed 2006-2015 in Sweden, were identified from the National Register for Esophageal and Gastric Cancer (NREV). In a multivariable analysis, a higher rate of treatment with curative intent (time ratio 1.17 [1.05-1.30], p<0.001) and a higher resection rate (time ratio 1.24 [1.12-1.37], p<0.001) were associated with improved survival.

Fifty anonymized esophageal cancer cases were distributed to five expert MCCs. In estimations of T-stage, the MCCs were in total agreement in eight of 50 cases (16%). For N-stage, total agreement was seen in 17 cases (34%) and for clinical M-stage in 34 cases (68%). The MCCs agreed on recommended treatment in 26/50 cases (52%). 

In conclusion, the introduction of MIE resulted in a larger lymph node yield, without increased risk for complications. No difference in postoperative pleural effusion and atelectasis was seen on computed tomography five days after open esophagectomy compared with MIE. Patients diagnosed in a county with a higher curative intention rate and a higher rate of surgery had better five-year survival and there are differences in assessment of esophageal cancer patients at different MCCs.