Minimally invasive enucleation with zero ischemia for malignancies. The Cluj Napoca experience

We read, with great interest, the article “Laparoscopic enucleation of a giant submucosal esophageal lipoma. Case report and literature review”, published by Tsalis et al. [1]. The authors present an important surgical approach for the management of benign tumors of the esophagus, by performing a laparoscopic enucleation of a lower esophageal lipoma. By presenting the surgical experience of our university hospital, we wish to emphasize that minimally invasive enucleation is not only applicable for benign tumors, but also for malignant ones with comparable results regarding recovery of the patient, as well as long term survival.Minimally invasive enucleation is recommended for symptomatic benign tumors and for those greater than 5 cm, as presented by this surgical team, but lately this technique was applied also for malignancies because it has proven it’s usefulness regarding the delay in cancer progression and the reduction in surgical discomfort of the patient. Large clinical trails lack, but some reports have been published, as is the case of nephrectomy for the management of a secondary metastasis carried out by Cochetti et al. [2]. In their case, minimally invasive surgery allowed the preservation of renal function, as well as the possibility for the medical oncologists to continue adjuvant therapy. Consistent data from human clinical trails lacks, but these reports were preceded by animal studies,a s the one presented by Zhang et al. [3]. They approach small renal cell carcinomas by suggesting the use of a laparoscopic simple enucleation, followed by coagulation on the tumor bed using an argon beam coagulator, with excellent results regarding recovery and blood loss. Nephron sparing surgery is accompanied by adjuvant solutions such as the thallium laser assistance [4] or microwave ablation [5], with superior results in comparison with the radical nephrectomy for pT1a and pT1b carcinomas [6]. Apart from renal malignancies and rare benign tumors, as is the case of esophageal ones, laparoscopic enucleation with zero ischemia was also attempted by Makdissi et al. [7] in the case of four hepatocellular carcinoma cases and two benign liver tumors, with free pathology surgical margins and excellent post-surgical recovery. Our experience confirmed the usefulness of minimally invasive enucleation with minimal ischemia especially in the case of the patients where renal preservation is crucial because of pre-operative insufficiency or multiple renal lesions.The long-term survival is comparative with a standard partial nephrectomy, even if sometimes the histopathology results showed a pseudo capsule tumor invasion. Thus, minimally invasive enucleation should be performed not only for benign tumors, but also for aggressive cancers if the lesion is locally confined on preoperative imaging, easily delineated intraoperatively and does not seem to growly invade beyond the pseudocapsule.