Esophageal cancer (EC) is the 8th most common malignancy worldwide (1) with an estimated incidence of 456,000 new cases per year (2) and close to 17,000 cases in the US alone (3). Despite its relative infrequency, esophageal malignancy still remains a deadly disease with an overall 5-year survival of 18.7% (4) with the highest mortality rates occurring in Eastern Asia (14.1/100,000) (5). In the past 15 years, the management of EC has continued to evolve, however surgical resection remains the cornerstone of curative-intent treatment in early stage malignancy. While the histologic distribution of adenocarcinoma and squamous cell carcinoma can vary by risk factor and geographic location, the surgical management of both is essentially identical (6).
EC has been historically known as a difficult disease process to manage. The etiology may be multifactorial but a portion is owed to the unique presentation of this cancer. To date, no widely applicable screening methods for EC exist (7). In western nations, cancer screening and surveillance may be recommended for patients who are at high risk for Barrett’s Esophagus and routine screening may be beneficial for those who are Caucasian, obese, male, or have long standing reflux symptoms (8). On the other hand, areas with high disease burden in rural China have benefited from a population based approach to endoscopic screening (9).
Additionally patient reported symptoms for EC can be vague, requiring engaged providers and at times extensive work-up before a final diagnosis is made. Presentation symptomatology spans from dysphagia and weight loss (74% and 57% respectively) to gastrointestinal reflux and dyspnea (20% and 12% respectively) (10). The unique anatomy of the esophagus can further contribute as the lack of a true serosa may add to the skewed distribution of cancer stage at initial presentation (up to 69% of patients already have regional and distant spread) (11).
Guiding principles to surgical management
The efficacious treatment of EC is complex. Following diagnosis, which is most commonly achieved via endoscopic biopsy, appropriate staging is paramount as it guides management decisions and indeed the decision to proceed with endoscopic therapy versus surgery versus induction chemotherapy/chemoradiation hinges on the clinical TNM stage (12,13). While locoregionally advanced (≥ T3 or N+) cancers tend to be treated with neoadjuvant chemoradiation therapy, selection for upfront surgery is important as patients with early cancers (≤ T2N0) are the most likely to benefit from operative intervention (14). The recent publication of the results of a phase III trial recapitulate this fact when investigators terminated the study after determining that neoadjuvant treatment, specifically in early cancers, was unlikely to result in a survival benefit when compared to surgery alone (15). Moreover, endoscopic therapy—which allows for organ preservation—has been shown to be effective for the treatment of intramucosal cancers (16,17). To this end, the pre-operative assessment of cancer extent proves crucial and routine inclusion of CT/PET, endoscopic ultrasound, and endoscopic mucosal resection should be used to ensure accurate TNM classification (18-20). Following appropriate patient selection, surgical intervention can provide a durable treatment option, but regardless of the operative approach chosen, the need for R0 resection takes precedent as positive surgical margins confer a worse prognosis (21).
Surgery for EC
Esophageal surgery for the management of EC can be divided into anatomic regions. The management of cervical disease can be considered a functionally separate process which can require additional considerations given the physical proximity to structures such as the larynx. The use of neoadjuvant therapy (22-24) as well as pharyngo-laryngo-esophagectomy (PLE) (25,26) is beyond the scope of this article.
Ivor Lewis esophagogastrectomy (ILE)
Originally described by the Welsh surgeon Ivor Lewis in 1946 as a 2-staged procedure (27), the modern iteration of the eponymous operation consists of a single stage procedure utilizing both a laparotomy as well as a right thoracotomy. The abdominal incision allows conduit creation, which most commonly involves careful mobilization of the stomach and preservation of the right gastric and gastroepiploic arteries. The right thoracotomy allows for an upper thoracic anastomosis following resection of the involved portion of esophagus (28). This combined approach utilizing a thoracotomy and a laparotomy also allows for a two-field lymphadenectomy.
Transhiatal esophagectomy (THE)
The first cadaveric esophagectomy without a thoracotomy was described by the German anatomist Denk in 1913 and the first attempt in humans was performed in 1933 by British surgeon Turner (29,30). The modern application of this approach came to light in 1976 by Orringer (31) and utilizes abdominal and cervical neck incisions. A majority of the esophageal dissection is performed through the hiatus via the abdominal incision. The cervical incision allows for dissection of the proximal-most esophagus. The stomach conduit is constructed and then manipulated through the hiatus and brought to the neck where the esophagogastric anastomosis is constructed (32). This approach has been applied to malignancies in both the mid and distal esophagus, however larger mid-esophageal masses and/or masses in close approximation to the tracheal airway may not be best served by this approach (14). With the THE, only an abdominal lymphadenectomy can be performed as the thoracic esophagus is blindly dissected through the diaphragmatic hiatus.
The “three-hole” esophagectomy was first described by McKeown in 1969 and detailed a 3-incision procedure which was completed in a single stage (33). Unlike the transhiatal approach, the addition of a right thoracic incision allows for a more direct visualization of the esophageal dissection especially in anatomic areas close to the trachea. And although not addressed in the original description, the modern interpretation of the operation also allows for a thoracic esophageal lymphadenectomy (34).
As discussed, different surgical approaches may alter lymph node accessibility during EC resection. Japanese researchers described recurrence patterns of resected EC in the 1980s and noted that locoregional lymph nodes seemed to play an important role in disease recurrence (35). The adequacy of lymph node removal has been approached in two ways. Many Asian cohort based researchers have focused on the number of “fields” considered for lymph node dissection, with “two-field” encompassing abdominal and thoracic basins and “three-field” including the cervical esophagus (36). Alternatively other researchers have approached lymphadenectomy in terms of raw lymph node harvest (37).
To date, no definitive recommendation has been made for the number of fields required for adequacy. Recent meta-analyses have attempted to examine a collection of mostly retrospective studies. Ma et al. and Ye et al. found that a three-field approach may result in better overall survival, however this is at the cost of possibly increased morbidity including recurrent nerve damage and anastomotic leak (36,38). The lack of clear, prospective data has resulted in an ongoing clinical trial which is attempting to address the need for a three-field dissection versus two (NCT01807936).
In terms of lymph node harvest, Rizk et al. demonstrated in a retrospective examination of 336 patients that staging was best stratified if a minimum of 18 lymph nodes were harvested and that prognosis could be delineated by three categories of nodal involvement (0, 1–4, >4 nodes) (39). Rizk et al. subsequently utilized data from 4,627 patients in the Worldwide EC Collaboration database and recommended target lymph node harvest based on T-classification: 10 nodes for pT1, 20 for pT2, and ≥30 for pT3/T4 (37). Studies overall vary on the exact number of nodes needed for accurate staging and prognostication, however based on this work as well as others, current National Comprehensive Cancer Network (NCCN) guidelines have adopted a recommendation of at least 15 harvested nodes (23,39-41).
More recent studies have suggested that the extent of lymphadenectomy is not only associated with staging but it is also independently associated with overall survival (40,42,43). This is particularly true for early stage tumors, suggesting that EC is not always a systemic disease but indeed there is a phase when the tumor is loco-regional (44).
Transthoracic esophagectomy (TTE) versus THE
Although the utility of surgical resection in early stage EC is well agreed upon, the ideal approach has been a matter of debate. There are generally two categories of surgical approach, one which involves a thoracic incision (McKeown and Ivor Lewis) and one which does not (THE). The question arises whether the use of thoracic exposure allows for a superior oncologic resection while its omission may allow for a less morbid procedure.
Rentz et al. used prospectively collected US based data from the Veteran Affairs National Surgical Quality Improvement Program for 945 patients. They found no difference in overall mortality between the approaches (10.0% TTE vs. 9.9% THE, P=0.983) as well as no difference in morbidity including respiratory failure, sepsis, anastomotic complications, or mediastinitis (45). Hulscher et al. performed a prospective trial in which 220 patients were randomized to TTE or THE. They found that THE was associated with less perioperative morbidity including shorter ICU and hospital stays, fewer pulmonary sequelae, and shorter duration of mechanical ventilation but that there was no difference in survival (median OS 1.8 vs. 2.0 years, P=0.38) (46). Although their initial study showed a trend towards improved survival in the TTE arm, a follow-up analysis of 5-year survival showed that there was no benefit (34% THE vs. 36% TTE, P=0.71) (47). Chang et al. utilized a US Medicare linked Surveillance, Epidemiology, and End Results database to examine 868 patients and noted that THE conferred a 30-day mortality benefit (6.7% vs. 13.1%, P=0.009) but that following adjustment for patient and provider characteristics, neither approach differed in 5-year survival (HR 0.95, 95% CI: 0.75–1.20) (48). In 2014, Papenfuss et al. examined 1,428 patients from the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database and found no difference in 30-day mortality (2.9% THE vs. 4.7% TTE, P=0.095) but that the TTE group required more returns to the operating room and more blood transfusions (14.5% vs. 10.9%, P=0.046 and 12.5% vs. 8.9%, P=0.032, respectively). Interestingly, Bhayani et al. examined 1,568 patients using the ACS-NSQIP as well and found that TTE was associated with increased pneumonia, ventilator dependence, and septic shock (OR 1.47, 1.35, 1.86 and P=0.007, 0.04, 0.001, respectively) but did not identify a mortality benefit (49). Like all population-based studies, these are limited by the administrative nature of data: there are no details on performance status, comorbidities, use of pre-operative chemotherapy, or institutional/surgeon volume. Moreover, these databases were not originally designed to answer questions of surgical technique thus subsequent extrapolation should be approached cautiously.
In our opinion a transthoracic approach allows for a more extensive lymphadenectomy, which seems to be associated with better survival especially in early stage cancer. Therefore, if the patient’s physical status allows it and the cancer can still be considered loco-regional (less than eight nodes involved) (44), a transthoracic approach is encouraged. Some of the complications related to a thoracotomy may be avoided with minimally invasive techniques.
Minimally invasive esophagectomy (MIE)
Given the benefits seen from minimally invasive approaches to other surgical procedures, the use of similar techniques began to be applied to surgery of the esophagus (50,51). Minimally invasive approaches generally utilize laparoscopy with the addition of thoracoscopy if a thoracic dissection is planned. Indeed after its initial introduction, the utilization of MIE has continued to rise (52). Luketich et al. sought to prospectively evaluate MIE and performed a phase II feasibility trial of 95 patients and found it to have acceptable mortality and morbidity (53). Biere et al. conducted a randomized control trial to compare open versus MIE in 115 patients and found that the minimally invasive approach was associated with fewer pulmonary infections in the early post-operative period (54). Three-year follow-up data from the same trial was recently analyzed and noted no difference in overall survival or disease free-survival (55). As other studies are underway to evaluate the long-term benefits of the MIE approach and as more MIE programs are developed around the world, it is important to note that the benefits of MIE are subject to a learning curve and that surgeon and center experience plays a role in patient outcome (56,57).
Outcomes and complications
Much of the historical aversion to the application of esophagectomy likely stemmed from high early mortality rates (58,59). However updated techniques and perioperative management have resulted in a safe and beneficial operation. Yet, the reporting of more modern outcomes have been varied and at times inconsistent resulting in an effort to standardize the data collection and reporting of complications associated with esophagectomy (60,61). Furthermore, the complexity of the procedure and the peri-operative management has led to a national and international trend to centralize surgeons and medical centers who undertake the management of EC and this has in turn resulted in additional improvements of patient outcomes (62-65).
The management of EC is complex and requires particular experience during every step of treatment including operative and peri-operative care. The late and vague presentation of the disease process can pose a difficult diagnostic and therapeutic situation; however in early stage cancers, complete resection is the only potentially curative treatment. Current clinical investigations as well as ongoing refinements in peri-operative care will be essential in the movement to even further improve EC management and patient outcomes.
Conflicts of Interest: The authors have no conflicts of interest to declare.
- Torre LA, Siegel RL, Ward EM, et al. Global Cancer Incidence and Mortality Rates and Trends--An Update. Cancer Epidemiol Biomarkers Prev 2016;25:16-27. [Crossref] [PubMed]
- Arnold M, Soerjomataram I, Ferlay J, et al. Global incidence of oesophageal cancer by histological subtype in 2012. Gut 2015;64:381-7. [Crossref] [PubMed]
- Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin 2017;67:7-30. [Crossref] [PubMed]
- Dubecz A, Gall I, Solymosi N, et al. Temporal trends in long-term survival and cure rates in esophageal cancer: a SEER database analysis. J Thorac Oncol 2012;7:443-7. [Crossref] [PubMed]
- GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. Available online: http://globocan.iarc.fr
- Wheeler JB, Reed CE. Epidemiology of esophageal cancer. Surg Clin North Am 2012;92:1077-87. [Crossref] [PubMed]
- Pennathur A, Gibson MK, Jobe BA, et al. Oesophageal carcinoma. Lancet 2013;381:400-12. [Crossref] [PubMed]
- Shaheen NJ, Falk GW, Iyer PG, et al. ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus. Am J Gastroenterol 2016;111:30-50. [Crossref] [PubMed]
- Zheng X, Mao X, Xu K, et al. Massive Endoscopic Screening for Esophageal and Gastric Cancers in a High-Risk Area of China. PLoS One 2015;10:e0145097. [Crossref] [PubMed]
- Daly JM, Fry WA, Little AG, et al. Esophageal cancer: results of an American College of Surgeons Patient Care Evaluation Study. J Am Coll Surg 2000;190:562-72; discussion 572-3. [Crossref] [PubMed]
- SEER Cancer Statistics Review, 1975-2013. Available online: https://seer.cancer.gov/
- Berry MF. Esophageal cancer: Staging system and guidelines for staging and treatment. J Thorac Dis 2014;6 Suppl 3:S289-97. [PubMed]
- Stahl M, Mariette C, Haustermans K, et al. Oesophageal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2013;24 Suppl 6:vi51-6. [Crossref] [PubMed]
- D'Amico TA. Outcomes after surgery for esophageal cancer. Gastrointest Cancer Res 2007;1:188-96. [PubMed]
- Mariette C, Dahan L, Mornex F, et al. Surgery alone versus chemoradiotherapy followed by surgery for stage I and II esophageal cancer: final analysis of randomized controlled phase III trial FFCD 9901. J Clin Oncol 2014;32:2416-22. [Crossref] [PubMed]
- Pech O, May A, Manner H, et al. Long-term efficacy and safety of endoscopic resection for patients with mucosal adenocarcinoma of the esophagus. Gastroenterology 2014;146:652-60.e1. [Crossref] [PubMed]
- Molena D, DeMeester SR. The dilemma of T1 esophageal adenocarcinoma. J Thorac Cardiovasc Surg 2017;153:1206-7. [Crossref] [PubMed]
- Hong SJ, Kim TJ, Nam KB, et al. New TNM staging system for esophageal cancer: what chest radiologists need to know. Radiographics 2014;34:1722-40. [Crossref] [PubMed]
- van Vliet EP, Heijenbrok-Kal MH, Hunink MG, et al. Staging investigations for oesophageal cancer: a meta-analysis. Br J Cancer 2008;98:547-57. [Crossref] [PubMed]
- Rice TW, Ishwaran H, Ferguson MK, et al. Cancer of the Esophagus and Esophagogastric Junction: An Eighth Edition Staging Primer. J Thorac Oncol 2017;12:36-42.
- Chan DS, Reid TD, Howell I, et al. Systematic review and meta-analysis of the influence of circumferential resection margin involvement on survival in patients with operable oesophageal cancer. Br J Surg 2013;100:456-64. [Crossref] [PubMed]
- Strong VE, D'Amico TA, Kleinberg L, et al. Impact of the 7th Edition AJCC staging classification on the NCCN clinical practice guidelines in oncology for gastric and esophageal cancers. J Natl Compr Canc Netw 2013;11:60-6.
- Esophageal and esophagogastric junction cancers version 2.2016. Available online: https://www.nccn.org
- Stahl M, Budach W, Meyer HJ, et al. Esophageal cancer: Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2010;21 Suppl 5:v46-9. [Crossref] [PubMed]
- Tong DK, Law S, Kwong DL, et al. Current management of cervical esophageal cancer. World J Surg 2011;35:600-7. [Crossref] [PubMed]
- Morita M, Saeki H, Ito S, et al. Technical improvement of total pharyngo-laryngo-esophagectomy for esophageal cancer and head and neck cancer. Ann Surg Oncol 2014;21:1671-7. [Crossref] [PubMed]
- Lewis I. The surgical treatment of carcinoma of the oesophagus; with special reference to a new operation for growths of the middle third. Br J Surg 1946;34:18-31. [Crossref] [PubMed]
- Reed CE. Technique of open Ivor Lewis esophagectomy. Oper Tech Thorac Cardiovasc Surg 2009;14:160-75. [Crossref]
- Hankins JR, Attar S, Coughlin TR, et al. Carcinoma of the esophagus: A comparison of the results of transhiatal versus transthoracic resection. Ann Thorac Surg 1989;47:700-5. [Crossref] [PubMed]
- Turner GG. Excision of thoracic esophagus for carcinoma with construction of extrathoracic gullet. Lancet 1933;2:1315-6. [Crossref]
- Orringer MB, Marshall B, Chang AC, et al. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg 2007;246:363-72; discussion 372-4. [Crossref] [PubMed]
- Reddy RM. Transhiatal esophagectomy. Oper Tech Thorac Cardiovasc Surg 2013;18:151-68. [Crossref]
- McKeown KC. Total three-stage oesophagectomy for cancer of the oesophagus. Br J Surg 1976;63:259-62. [Crossref] [PubMed]
- D’Amico TA. Mckeown esophagogastrectomy. J Thorac Dis 2014;6 Suppl 3:S322-4. [PubMed]
- Isono K, Onoda S, Okuyama K, et al. Recurrence of intrathoracic esophageal cancer. Jpn J Clin Oncol 1985;15:49-60. [PubMed]
- Ma GW, Situ DR, Ma QL, et al. Three-field vs two-field lymph node dissection for esophageal cancer: a meta-analysis. World J Gastroenterol 2014;20:18022-30. [Crossref] [PubMed]
- Rizk NP, Ishwaran H, Rice TW, et al. Optimum lymphadenectomy for esophageal cancer. Ann Surg 2010;251:46-50. [Crossref] [PubMed]
- Ye T, Sun Y, Zhang Y, et al. Three-field or two-field resection for thoracic esophageal cancer: a meta-analysis. Ann Thorac Surg 2013;96:1933-41. [Crossref] [PubMed]
- Rizk N, Venkatraman E, Park B, et al. The prognostic importance of the number of involved lymph nodes in esophageal cancer: implications for revisions of the American Joint Committee on Cancer staging system. J Thorac Cardiovasc Surg 2006;132:1374-81. [Crossref] [PubMed]
- Peyre CG, Hagen JA, DeMeester SR, et al. The number of lymph nodes removed predicts survival in esophageal cancer: an international study on the impact of extent of surgical resection. Ann Surg 2008;248:549-56. [PubMed]
- Groth SS, Virnig BA, Whitson BA, et al. Determination of the minimum number of lymph nodes to examine to maximize survival in patients with esophageal carcinoma: data from the Surveillance Epidemiology and End Results database. J Thorac Cardiovasc Surg 2010;139:612-20. [Crossref] [PubMed]
- Samson P, Puri V, Broderick S, et al. Extent of Lymphadenectomy Is Associated With Improved Overall Survival After Esophagectomy With or Without Induction Therapy. Ann Thorac Surg 2017;103:406-15. [Crossref] [PubMed]
- Schwarz RE, Smith DD. Clinical impact of lymphadenectomy extent in resectable esophageal cancer. J Gastrointest Surg 2007;11:1384-93; discussion 1393-4. [Crossref] [PubMed]
- Peyre CG, Hagen JA, DeMeester SR, et al. Predicting systemic disease in patients with esophageal cancer after esophagectomy: a multinational study on the significance of the number of involved lymph nodes. Ann Surg 2008;248:979-85. [Crossref] [PubMed]
- Rentz J, Bull D, Harpole D, et al. Transthoracic versus transhiatal esophagectomy: A prospective study of 945 patients. J Thorac Cardiovasc Surg 2003;125:1114-20. [Crossref] [PubMed]
- Hulscher JB, van Sandick JW, de Boer AG, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 2002;347:1662-9. [Crossref] [PubMed]
- Omloo JM, Lagarde SM, Hulscher JB, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial. Ann Surg 2007;246:992-1000; discussion 1000-1. [Crossref] [PubMed]
- Chang AC, Ji H, Birkmeyer NJ, et al. Outcomes after transhiatal and transthoracic esophagectomy for cancer. Ann Thorac Surg 2008;85:424-9. [Crossref] [PubMed]
- Bhayani NH, Gupta A, Dunst CM, et al. Esophagectomies with thoracic incisions carry increased pulmonary morbidity. JAMA Surg 2013;148:733-8. [Crossref] [PubMed]
- Cuschieri A, Shimi S, Banting S. Endoscopic oesophagectomy through a right thoracoscopic approach. J R Coll Surg Edinb 1992;37:7-11. [PubMed]
- DePaula AL, Hashiba K, Ferreira EA, et al. Laparoscopic transhiatal esophagectomy with esophagogastroplasty. Surg Laparosc Endosc 1995;5:1-5. [PubMed]
- Lazzarino AI, Nagpal K, Bottle A, et al. Open versus minimally invasive esophagectomy: trends of utilization and associated outcomes in England. Ann Surg 2010;252:292-8. [Crossref] [PubMed]
- Luketich JD, Pennathur A, Franchetti Y, et al. Minimally invasive esophagectomy: results of a prospective phase II multicenter trial-the eastern cooperative oncology group (E2202) study. Ann Surg 2015;261:702-7. [Crossref] [PubMed]
- Biere SS, van Berge Henegouwen MI, Maas KW, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet 2012;379:1887-92. [Crossref] [PubMed]
- Straatman J, van der Wielen N, Cuesta MA, et al. Minimally Invasive Versus Open Esophageal Resection: Three-year Follow-up of the Previously Reported Randomized Controlled Trial: the TIME Trial. Ann Surg 2017;266:232-6. [Crossref] [PubMed]
- Tapias LF, Morse CR. Minimally invasive Ivor Lewis esophagectomy: description of a learning curve. J Am Coll Surg 2014;218:1130-40. [Crossref] [PubMed]
- Luketich JD, Schauer PR, Christie NA, et al. Minimally invasive esophagectomy. Ann Thorac Surg 2000;70:906-11. [Crossref] [PubMed]
- Müller JM, Erasmi H, Stelzner M, et al. Surgical therapy of oesophageal carcinoma. Br J Surg 1990;77:845-57. [Crossref] [PubMed]
- Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma: I. A critical review of surgery. Br J Surg 1980;67:381-90. [Crossref] [PubMed]
- Low DE, Alderson D, Cecconello I, et al. International Consensus on Standardization of Data Collection for Complications Associated With Esophagectomy: Esophagectomy Complications Consensus Group (ECCG). Ann Surg 2015;262:286-94. [Crossref] [PubMed]
- Zaninotto G, Low DE. Complications after esophagectomy: it is time to speak the same language. Dis Esophagus 2016;29:580-2. [Crossref] [PubMed]
- Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346:1128-37. [Crossref] [PubMed]
- Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117-27. [Crossref] [PubMed]
- Wouters MW, Karim-Kos HE, le Cessie S, et al. Centralization of esophageal cancer surgery: does it improve clinical outcome? Ann surg oncol 2009;16:1789-98. [Crossref] [PubMed]
- Henneman D, Dikken JL, Putter H, et al. Centralization of esophagectomy: how far should we go? Ann Surg Oncol 2014;21:4068-74. [Crossref] [PubMed]