Modern surgery for esophageal cancer

Abstract

Surgical treatment for esophageal cancer has made great progress in the past decades. It used to be a procedure of high mortality rate. With improvement in surgical techniques and peri-operative care, esophagectomy has been made relatively safe. In specialized centers, a mortality rate of less than 5% can be achieved. Morbidity rates remain high. The invasive surgery, especially with extended lymphadenectomy, performed on an elderly population with comorbidities, has its associated complications. Survival after treatment has improved, especially with increasing use of multimodality strategies. Minimally invasive surgery in the form of video-assisted thoracoscopic +/- laparoscopic esophagectomy, has become more popular. Equivalent, or even superior lymphadenectomy can be performed compared to open surgery. Some debatable aspects of minimally invasive esophagectomy remain, including its appropriate indication, lateral position vs. prone position, whether an intrathoracic or cervical esophageal anastomosis should be performed, and whether laparoscopic gastric mobilization should be an integral part of the procedure in addition to thoracoscopy, and if so, should the gastric conduit be prepared intra-corporeally or extra-corporeally. In over 200 minimally invasive esophagectomy performed at The University of Hong Kong, a mortality rate of 1% was achieved. Equivalent lymph node harvesting and survival was found compared to open surgery. Only one European multicenter randomized trial has been conducted comparing minimally invasive esophagectomy and open transthoracic resection. Less pulmonary complications were found. More trials are needed to truly prove its benefits. The results of surgery will improve further. The challenge of modern surgery is how best to individualize surgical procedures for patients with different stages of disease, comorbidities, and after neoadjuvant therapies.