General Thoracic Surgery (General Thoracic Surgery (Shields)) [2 VOLUME SET]

Editors: Shields, Thomas W.; LoCicero, Joseph; Ponn, Ronald B.; Rusch, Valerie W.

Title: General Thoracic Surgery, 6th Edition

Copyright 2005 Lippincott Williams & Wilkins

> Table of Contents > Volume II > The Esophagus > Section XXI - Operative Procedures in the Management of Esophageal Disease > Chapter 131 - Transthoracic Resection of the Esophagus

Chapter 131

Transthoracic Resection of the Esophagus

Jeffrey L. Port

Robert Korst

Nasser K. Altorki

Esophageal resection is most frequently performed for carcinoma of the esophagus. However, esophagectomy is also occasionally necessary in the treatment of some benign esophageal diseases such as irreparable or neglected perforations, end-stage achalasia, intractable peptic structures, and recurrent failures after antireflux surgery.

Although esophageal carcinoma is uncommon in the United States, Blot (1995) and Blot and McLaughlin (1999) reported that its incidence (particularly that of adenocarcinoma) has risen dramatically during the past decade. Surgical resection remains the standard of care because multiple randomized trials have shown essentially no survival benefit after induction chemotherapy or chemoradiation therapy when compared with surgery alone. However, there is ongoing controversy regarding the preferred surgical strategy that relates mainly to the surgical approach (transhiatal or transthoracic) and the extent of lymphadenectomy (Table 131-1). Most surgeons regard esophageal cancer as a systemic disease at the time of diagnosis, with palliation being the essential surgical objective. In that paradigm, surgical cure is essentially a chance phenomenon. Overall, 5-year survival rates have remained in the 20% to 30% range with or without preoperative therapy.

A few surgical groups have advocated a radical approach to esophageal carcinoma. En bloc esophagectomy involves resection of the esophagus within a wide envelope of adjoining mediastinal tissue accompanied by a thorough dissection of the mediastinal and upper abdominal retroperitoneal lymph nodes. More recently, further extension of the operations included dissection of lymph nodes in the superior mediastinum and lower neck. Although the 5-year survival after these extended resections has been encouraging, they remain controversial in most of Western Europe and the United States.

HISTORICAL BACKGROUND

The surgical treatment of esophageal carcinoma has evolved rapidly over a very short time span. Although partial esophageal resections were attempted in the 19th century, Naef (1990) described that early in the 20th century, respected surgeons such as Sauerbruch declared that resection of the midesophagus was impossible. However, Franz Torek accomplished this feat on March 14, 1913. He performed an esophagectomy through the left chest with considerable efforts to dissect the esophagus behind the aortic arch and with a resultant injury to the left main bronchus, which was repaired. The patient survived with a cervical esophagostomy and gastrostomy for 13 years.

Intrathoracic restoration of esophagogastric continuity would have to wait until 1933 when the Japanese surgeon Oshawa and, soon after, the American surgeons Marshall (1938) and Adams and Phemister (1938) accomplished an esophagogastric anastomosis for distal esophageal carcinomas. In 1942, Churchill and Sweet delivered their paper on Transthoracic resection of tumors of the stomach and esophagus, which ushered in the modern era of transthoracic approaches to esophageal lesions. Garlock and Sweet successfully proceeded more proximally and performed a supraaortic esophagogastrostomy with placement of the conduit in front of the aorta, as described by Garlock (1967). Sweet became the leading authority in esophageal surgery. His preliminary report Surgical management of the midthoracic esophagus outlined techniques that have become the foundation of modern esophageal surgical teachings and are still relevant.

The left-sided transthoracic approach to the esophagus had its shortcomings. Numerous patients had postoperative complications related to respiratory distress that was a result of the radial incision in the diaphragm. Also, the blind dissection behind the aortic arch could be challenging. The British surgeon Ivor Lewis (1946) proposed a right-sided approach, which allowed for dissection of the midesophagus under direct vision and did not require a diaphragmatic incision. It did not take long to convert thoracic surgeons to the Ivor Lewis approach for proximal and midesophageal lesions, whereas the left-sided Sweet approach was reserved for distal carcinomas. The fear of pleural leakage from an intrathoracic anastomosis motivated surgeons

P.1988

Logan (1963) was first to characterize an en bloc resection of the esophagus and surrounding tissues with adequate proximal and distal margins. Although the operative mortality was high, the 5-year survival that was achieved was unparalleled. Skinner resurrected that approach in 1979 and published his first report in 1983. At the same time, a revival was under way for esophagectomy without thoracotomy led by Orringer and Sloan (1978), and the stage was set for the current debate of the best surgical approach for esophageal cancer.

PREOPERATIVE EVALUATION

Preoperative evaluation should be aimed at establishing the histologic diagnosis, determining the extent of local and distant disease, and evaluating the patient's physiologic status. Radiologic evaluation should include an upper gastrointestinal series and a computed tomography (CT) scan of the chest and abdomen. A barium swallow will document the location and length of the lesion and should include the stomach and duodenum. A CT scan will establish the local extent of the tumor, including mural penetration and infiltration into adjacent tissues, and may suggest nodal involvement or distant metastases. Endoscopy should be performed, preferably by the operating surgeon. During endoscopy, attention should be directed to identifying the relationship of the tumor to the cricopharyngeus, the squamocolumnar junction, and the diaphragmatic hiatus. It is also important to note the presence and extent of Barrett's esophagus and the presence of satellite lesions. This information is invaluable and may affect the decision on the extent and approach for esophagectomy. Bronchoscopy is important when evaluating tumors of the upper and middle third of the esophagus, to assess vocal cord function and major airway involvement.

Routine CT scans will detect the primary tumor in 75% of cases. However, as reported by Chandawarkar and colleagues (1996), CT sensitivity for locoregional nodal disease can be as low as 50%. To improve on esophageal cancer staging, endoscopic ultrasound (EUS) has quickly been established as an invaluable tool in evaluating the depth of tumor penetration and involvement of regional lymph nodes and should be used in patients being considered for neoadjuvant therapy. Lightdate (1994) reported that EUS appears to have a diagnostic accuracy of 80% in predicting the T status and a 70% accuracy in predicting the N status. Also, transesophageal needle biopsy of periesophageal or perigastric nodes can often be performed with ultrasound guidance.

Thoracoscopy and laparoscopy have recently been reported as staging modalities for esophageal cancer. These techniques offer the potential to assess the extent of lymph node involvement, identify serosal and peritoneal implants, identify liver metastases, and perhaps most importantly, detect T4 disease. Krasna (1996) reported a 93% staging accuracy using thoracoscopic and laparoscopic techniques for staging esophageal carcinomas. Overall, the data suggest that minimally invasive surgical techniques may provide some added benefit to conventional studies in assessing esophageal carcinoma.

All esophageal cancer patients must have a careful assessment of their pulmonary and cardiac status before resection. Many of these patients when questioned are current smokers who must be counseled to abstain for at least 2 weeks before resection. The length of the procedure and high incidence of complications necessitate that elective surgery be performed only when comorbidities have been optimally managed. As reported by Marmuse and Maillochaud (1999), most patients undergoing esophagectomy have coexisting pulmonary and cardiac disease and, for this reason, pulmonary function tests and cardiac stress studies are often obtained. The incidence of postoperative complications can be greatly diminished by simple measures such as smoking cessation and a short course of antibiotics and inhaled bronchodilators.

P.1989

ANESTHETIC MANAGEMENT

Patients undergoing a transthoracic esophagectomy should have an epidural catheter placed for postoperative pain control. In addition, a double-lumen endotracheal tube will allow for single-lung ventilation and greatly enhance the exposure. A radial artery catheter for continuous blood pressure monitoring is recommended. Two large-bore peripheral intravenous catheters should be inserted and urinary output monitored with a Foley catheter.

SURGICAL MANAGEMENT

There are a variety of surgical approaches for esophageal resection. The choice of the approach must take into consideration the tumor's location, the patient's condition and body habitus, prior operations, prior irradiation, the proposed esophageal substitute, the extent of node dissection, and the surgeon's preference. Transthoracic esophagectomy is one of the most common approaches to esophageal resection and can be performed through either a right or left thoracotomy. Typically, tumors of the middle and upper esophagus are approached through a right thoracotomy, whereas tumors of the distal third of the esophagus or gastroesophageal junction are approached through a left thoracotomy. In either case, the esophagus is mobilized from its mediastinal bed along with periesophageal lymph nodes, and no effort is made to perform a more radical nodal dissection. Reconstruction is most commonly performed using a gastric conduit with either an intrathoracic or cervical anastomosis.

Ivor Lewis Esophagectomy

Historically, the Ivor Lewis esophagectomy was a two-staged procedure. A laparotomy was performed with gastric mobilization followed 1 week later by thoracotomy, esophagectomy, and esophagogastric anastomosis. This was a radical deviation from the standard of blunt esophagectomy, cervical esophagostomy, gastrostomy, and later skin tube reconstruction. Mathisen and associates (1988) stated that the evolved one-stage Ivor Lewis procedure has become the benchmark procedure against which all approaches are currently measured. Indications for an Ivor Lewis esophagectomy, other than carcinoma, include high-grade dysplasia, caustic esophageal injury, and complications of esophageal reflux with previously failed antireflux procedures. The Ivor Lewis procedure is not indicated in patients with carcinomas of the upper third of the esophagus or those straddling the thoracic inlet.

The patient is first positioned supine, and a limited upper midline incision is created. Full abdominal exploration ensues, with special attention paid to evidence of tumor dissemination in the form of peritoneal and serosal implants, liver metastases, and celiac nodal disease. Barring evidence of unresectability, the incision is extended. An abdominal self-retaining retractor such as the Omni, Buchwalter, or Goligher retractor is useful. The left lobe of the liver can be retracted cephalad or the triangular ligament divided and the lateral segment of the left lobe retracted to the right.

The lesser sac is then entered safely away from the right gastroepiploic artery and the greater omentum divided along the greater curvature. Next, the stomach is retracted cephalad with special attention not to grab or impinge on the gastroepiploic vessels, and the short gastric vessels are sequentially ligated and divided (Fig. 131-1). One must ensure that the stomach wall not be included in the ligature to prevent gastric necrosis. With the stomach retracted upward, the left gastric vessels are individually ligated (Fig. 131-2). The right gastric artery is preserved. Division of the gastrohepatic ligament completes gastric mobilization. Next, the intraabdominal esophagus is dissected from its hiatal attachments. The hiatus is then manually enlarged to accommodate easily the esophageal substitute. A Kocher maneuver is performed, and a pyloromyotomy is constructed. Much of the dissection of the distal esophagus can be performed bluntly through the abdomen. This dissection can be performed under direct vision up to the level of the inferior pulmonary ligament. Before completion of the abdominal portion of the Ivor Lewis procedure, a feeding jejunostomy tube is placed. The abdomen is then closed and the patient repositioned to a left lateral decubitus position for a right thoracotomy.

P.1990

A posterolateral thoracotomy is performed through the fifth interspace, and the serratus muscle is spared. The right lung is selectively deflated and retracted anteriorly. First, the azygos vein is transected with an Endo-GIA vascular stapler (U.S. Surgical, Norwalk, CT), and the pleura overlying the esophagus is opened sharply anterior to the azygos vein (Fig. 131-3). The esophagus is then dissected circumferentially in the region above the tumor, and an umbilical tape is looped around it for traction. The dissection should be carried to within centimeters of the inlet. Inferiorly, the esophagus is dissected from its bed circumferentially to the hiatus. Lymphatics should be ligated to decrease the incidence of chylothorax.

The stomach is pulled into the chest through the widened hiatus, and the stomach is divided and tubularized with two to three firings of the GIA stapler (Fig. 131-4). This staple line should be reinforced with interrupted Lembert sutures. The esophagogastrectomy can be performed in a variety of ways, including the use of an EEA surgical stapler passed through a gastrostomy using at least a 25-mm stapler. Our preference is a hand-sewn anastomosis that can be created using continuous absorbable suture, interrupted at two or three points to avoid a purse-string effect. A nasogastric tube is positioned in the intrathoracic stomach. It is imperative to return any redundant stomach back into the abdomen to ensure proper gastric emptying. The edges of the gastric tube are sutured to the edge of the hiatus to prevent visceral herniation.

P.1991

McKeown Modification

McKeown described this three-stage variation in 1976. The technique allows for a greater length of esophagus to be resected and for the anastomosis to be placed in the cervical region (Fig. 131-5). Many surgeons prefer this approach for middle and upper esophageal lesions. Many adaptations to the original McKeown approach have been described. In the original approach, the patient is placed in the left lateral decubitus position with the right arm free draped to aid in the cervical portion of the procedure later. The table is turned to allow for the laparotomy, which is performed as previously described. The abdomen is closed and a standard right posterolateral thoracotomy performed. The thoracotomy approach is similar to what was previously described, but the upper esophagus is completely mobilized and separated from the trachea. A right oblique cervical incision is created anterior to the sternocleidomastoid muscle with division of the omohyoid muscle and inferior thyroid vein. The recurrent laryngeal nerve is preserved and the esophagus and stomach delivered into the neck for the anastomosis.

One variation to the original description involves performing the right thoracotomy first, especially if there is concern in regard to intrathoracic resectability. Following the mobilization of the esophagus and closure of the thoracotomy, the patient is turned to the supine position for a simultaneous abdominal and cervical approach. The esophagus is transected in the neck and a Penrose drain sutured to the cut specimen end before it is delivered through the mediastinum into the abdomen. After preparation of the gastric tube, the specimen is sent off the field and the gastric conduit advanced into the neck, guided by the Penrose drain.

Left Transthoracic Approach

A left transthoracic approach provides excellent exposure of the lower mediastinum, hiatal tunnel, and upper abdomen, and is ideally suited for patients with tumors of the lower third of the esophagus and gastroesophageal junction. However, it remains a relatively uncommon approach because of lack of familiarity with the anatomy of the upper abdomen as viewed from the thorax and a perceived difficulty in performing some of the maneuvers such as a Kocher maneuver and a pyloromyotomy.

P.1992

The patient is placed in the right lateral decubitus position with the table flexed. A skin incision is made from the posterior axillary line to the costal margin (Fig. 131-6). The sixth interspace is entered without transecting the costal arch. Although others have recommended the division of the costal arch, we do not find this necessary for adequate exposure, and its division may add to postoperative discomfort. The mediastinal pleura is incised, and the esophagus is mobilized and encircled with a Penrose drain (Fig. 131-7). Next, the diaphragm is incised in a semilunar fashion from sternum to spleen to minimize phrenic injury and to facilitate later diaphragmatic closure (Fig. 131-8). The abdomen is explored to assess resectability, and the stomach is mobilized as previously described. The stomach is then brought through the hiatus (Fig. 131-9). The esophagus is transected 8 to 10 cm proximal to the tumor, and the stomach is divided distally, creating a greater curvature tube for reconstruction. The gastric conduit is passed through the hiatus, and the anastomosis can be performed either in the mediastinum or, preferably, in the neck. The latter is accomplished by bluntly mobilizing the

P.1993

En Bloc Resection

The prospects of prolonged survival for patients with esophageal carcinoma remain as dismal as they were decades ago despite improvements in perioperative care and the introduction of neoadjuvant therapy. This, coupled with the dramatic increase in the incidence of adenocarcinoma of the esophagus, lends urgency to the development of improved techniques for this disease. Debate continues on the efficacy of radical esophageal resections, with most surgeons favoring the more limited transthoracic or transhiatal approaches. However, we and others continue to advocate an en bloc approach to resection of the esophagus in hope of altering the natural history of this disease.

The basic principle underlying the operation is resecting the tumor-bearing esophagus with a wide envelope of adjoining periesophageal tissue that includes both pleural surfaces laterally and pericardium anteriorly. The lymphatics between the esophagus and aorta, including the thoracic duct, are resected en bloc with the esophagus, along with the surrounding mediastinal lymph nodes from the tracheal bifurcation to the hiatus. Also, an upper abdominal lymphadenectomy is performed that includes the common hepatic, celiac, left gastric, lesser curvature, parahiatal, and retroperitoneal nodes.

A right thoracotomy through the fifth interspace is performed for carcinomas of the upper and middle thirds or those of the lower third that are within 10 cm of the aortic arch. The pleura is incised just anterior to the main trunk of the azygos vein throughout its course. The dissection proceeds leftward toward the aortic adventitia, thus mobilizing the thoracic duct throughout its course in the lower and middle mediastinum (Figs. 131-10 and 131-11). The duct is

P.1994

The patient is repositioned for a simultaneous laparotomy and cervical incision. A limited upper abdominal midline incision is created. Full abdominal exploration ensues, with special attention paid to evidence of tumor dissemination in the form of peritoneal and serosal implants and liver metastases. An abdominal self-retaining retractor such as the Omni (Omni-Tract Surgical, St. Paul, MN) is useful. The omentum is dissected off of the transverse colon and transected several centimeters from the gastroepiploic arcade. The peritoneum is incised along the top of the pancreas, and all lymphatic tissue overlying the crura is taken with the specimen (Fig. 131-14). This includes a thorough dissection of the celiac, splenic, and common hepatic lymph nodes. The neck is opened through a low collar incision off to the same side as the thoracotomy, and the mobilized esophagus is delivered into the wound and transected (Fig. 131-15). The specimen is brought through the hiatus into the abdomen and transected distally (Fig. 131-16). The stomach is transected from the fundus to the third or fourth branch of the left gastric artery. This preserves a full length of stomach for advancement into the neck. Less frequently, a segment of isoperistaltic left and transverse colon can be used for reconstruction.

The gastric tube is advanced through the posterior mediastinum to the neck (Fig. 131-17). The anastomosis is performed as a single-layer running anastomosis with a

P.1995

Resection of Lower-Third Tumors

A left sixth interspace thoracotomy is performed for carcinomas of the lower esophagus when a 10-cm margin proximal to the tumor can be obtained. This incision provides excellent exposure to the lower mediastinum, hiatal tunnel, and upper abdomen. A thoracoabdominal incision is almost never necessary. Access to the abdomen is achieved through a peripherally placed semilunar incision of the left hemidiaphragm. The diaphragmatic incision extends from the back of the sternum anteriorly to the spleen posteriorly. The thorax and abdomen are carefully assessed for visceral metastases, and the tumor is assessed for mobility. The omentum is detached from the colon in the avascular plane, carefully preserving the gastroepiploic vessels. Dissection proceeds along the superior border of the pancreas, sweeping all retroperitoneal lymphatics and areolar tissue toward the esophageal hiatus. The left gastric artery and vein are dissected at their origin and transected. Using the cautery, a 1-inch cuff of diaphragm is resected circumferentially around the esophagus. The thoracic duct is identified, ligated, and transected as it passes through the aortic hiatus. After completion of the abdominal portion of the operation, the posterior mediastinectomy begins by incising the mediastinal pleura overlying the aorta from the aortic arch to the

P.1996

The digestive tract is divided 10 cm on either side of the tumor. Reconstruction can be performed in the subaortic position, or, alternatively, the esophagus is dissected underneath the aortic arch and into the neck. The conduit is then passed under the arch, and both the conduit and esophageal stump are gently placed into the prevertebral cervical space in preparation for a cervical anastomosis performed through a separate cervical incision. The diaphragm is reattached with interrupted nonabsorbable sutures, and the conduit is sutured to the hiatus. The chest incision is closed with bilateral pleural drainage.

Our choice for esophageal replacement is determined by the stage of disease and the general condition of the patient. A gastric conduit is used most frequently for reconstruction, except in relatively young patients with early-stage disease, in whom an isoperistaltic colon interposition may be used. Regardless of the conduit, the anastomosis is performed with 3 0 or 4 0 absorbable monofilament suture.

Three-Field Nodal Dissection

The extension of the lymphadenectomy for carcinoma of the thoracic esophagus to include the superior mediastinal and cervical lymph nodes (three-field node dissection) was introduced by Japanese surgeons. This was prompted by

P.1997

The three-field dissection is usually performed through a right thoracotomy. The previously described posterior mediastinectomy is initially performed up to the level of the arch of the azygos vein. The prevertebral and retrotracheal attachments of the esophagus are divided and the organ mobilized to the neck. The left recurrent nerve is exposed near its origin and dissected to the thoracic inlet, and its adjacent lymph nodes are excised. The right recurrent nerve is exposed as it loops around the subclavian artery, and the adjoining chain of nodes is dissected well into the neck (Fig. 131-20). Although the recurrent nodes are described as having a cervical component, most of this dissection can be accomplished through the chest. In the neck, an infraomohyoid node dissection is performed. The abdominal and cervical dissections are accomplished through the subsequent combined cervical and abdominal approaches, as previously described in the en bloc section (Fig. 131-21).

POSTOPERATIVE MANAGEMENT

In the past, mechanical ventilation was maintained until the following postoperative day. Currently, with improved pulmonary physiotherapy and epidural pain control, patients are extubated immediately following two-field en bloc resection. Patients who undergo the three-field dissection often require 24 hours of mechanical ventilation and subsequently special attention to bronchopulmonary hygiene as a result of the often-associated bronchorrhea. Following radical resections (two- or three-field), patients

P.1998

Management of Complications

Anastomotic Leaks

A small anastomotic leak that is detected on a routine barium swallow and that appears to drain back into the esophageal lumen usually heals without intervention. Larger, uncontained leaks require adequate drainage, usually simply by opening the neck wound at the bedside. On rare occasion, a leak from a cervically placed anastomosis can track into the mediastinum or pleural space. In such instances, drainage can usually be accomplished by tube thoracostomy. Thoracotomy is rarely necessary except in the face of persistent sepsis or multiloculated fluid collections. In complicated anastomotic leaks (large leaks or ongoing sepsis), esophagoscopy may be useful to determine viability of the conduit. Necrosis of the conduit should be treated by resection, cervical esophagostomy, and reconstruction at a later date.

Anastomotic Stricture

In many reports, 30% to 50% of patients develop a stricture at the anastomosis by 3 months after surgery. Dilatation of this stricture can be accomplished by several means.

Delayed Gastric Emptying

Clinically significant delayed gastric emptying is uncommon. Common causes of delayed gastric emptying include the lack of a pyloric drainage procedure, obstruction at a tight hiatus, or a redundant intrathoracic stomach. Balloon dilation of the pylorus can be attempted along with the addition of prokinetic agents such as pantoprazole sodium (Protonix) and erythromycin. However, if conservative management fails, the patient may require reoperation and an adequate drainage procedure.

Reflux

Reflux is a common problem after gastric pull-up. It appears that the level of severity varies with the level of the anastomosis. Anastomoses above the azygos vein have a lower incidence of reflux than similarly constructed anastomoses below the vein. Reflux is particularly severe if the anastomosis is in the lower mediastinum. Conservative measures such as frequent smaller feedings, avoidance of liquids with meals, and not reclining after meals may alleviate symptoms.

RESULTS

Standard Transthoracic Esophagectomy

Multiple retrospective surgical series have reported the results of transthoracic esophagectomy, and extreme variability of the results have been recorded. Undoubtedly, this variability has been due to differences in patient selection and surgical expertise. Resectability rates are in the range of 70% to 90%, hospital mortality rates vary from 0% to 10%, and 5-year survival rates are anywhere from 8% to 27% (Table 131-2). In one of the largest series in North America, Ellis (1999) reported his experience with 455 transthoracic esophagectomies. The hospital mortality rate

P.1999

These results are similar to those reported from the control surgical arms in multiple randomized trials that evaluated the efficacy of preoperative chemotherapy and radiation therapy compared with surgery alone. In the North American Intergroup trial, Kelsen and associates (1998) compared patients who received preoperative chemotherapy followed by esophagectomy with patients who underwent esophagectomy alone. In the control arm, most of the 227 resected patients underwent a transthoracic esophagectomy. The hospital mortality rate was 6%, and major complications occurred in 26% of patients. The actuarial 5-year survival rate was 20%.

The local recurrence following transthoracic esophagectomy has been reported in the range of 30% to 50%. In the Intergroup trial, the control arm had a local recurrence rate of 31%. Similarly, Nygaard and associates (1992) reported a 35% local recurrence rate in the control arm of a four-arm randomized trial.

En Bloc Esophagectomy

As reported by one of us (NKA) (1999), between 1988 and 1998, 103 patients underwent the en bloc resection. The in-hospital mortality rate was 4.8% and was similar to institutional historical controls that had undergone a standard transthoracic esophagectomy earlier in our experience. Postoperative complications occurred in 40% of patients and were most often related to pulmonary complications. Overall and disease-free 5-year survival rates in the en bloc group were 46% and 40%, respectively (Fig. 131-22). One of us (NKA) and colleagues (1997) reported that patients with node-negative disease had a 68% survival rate, in comparison with a 27% survival rate for patients who underwent a standard transthoracic approach. Survival was also significantly better after en bloc resection for node-positive patients, 33% versus 13% (p = 0.002) (Fig. 131-23). Stage III patients had an impressive 5-year survival rate of 34%, compared with 11% after conventional transthoracic esophagectomy (p = 0.007) (Fig. 131-24). The survival advantage for stage III patients is especially significant when one considers that most esophageal cancer patients present with stage III disease. Local recurrence alone or in conjunction with systemic relapse occurred in 8% of patients. This compared favorably with recurrence rates reported after more conventional techniques.

Three-Field Node Dissection

Between 1994 and 2001, 80 patients (57 men, 23 women) with a median age of 61 years underwent an en bloc resection with a three-field node dissection at our institution, as reported by one of us (NKA) and co-workers (2002). Patients were eligible if their tumor was located in the tubular esophagus,

P.2000

P.2001

Fifty-five patients had postsurgical pathologically confirmed nodal metastases. Nodal metastases increased with increasing depth of tumor penetration into the esophageal wall (Table 131-4). Twenty-nine patients (36%) had metastatic carcinoma in the recurrent laryngeal or cervical nodes. Metastasis to the recurrent laryngeal-cervical nodes (cervicothoracic

P.2002

RANDOMIZED TRIALS COMPARING EN BLOC AND CONVENTIONAL ESOPHAGECTOMY

A single randomized trial has been reported by Hulscher and co-workers (2002) comparing transthoracic en bloc esophagectomy with conventional resection (transhiatal in this case). Although there was no statistically significant difference in survival between the two groups, there was a trend toward a survival benefit in the en bloc arm of the study. Overall and disease-free 5-year survival rates were 39% and 39%, respectively, in the en bloc group, compared with 29% and 27%, respectively, in the transhiatal group. Morbidity but not mortality was significantly higher in the en bloc group, consistent with the learning curve usually necessary with more complex procedures.

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Reading References

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