Esophageal cancer is typically treated through surgical resection, which involves removing part of the esophagus. The type of surgery depends on the location and stage of the cancer. Common procedures include McKeown esophagectomy, transhiatal esophagectomy, and Ivor Lewis esophagectomy. While esophagectomy is a major surgery with risks of complications, minimally invasive techniques and extensive lymph node dissection may improve short and long-term outcomes for patients.

1. Selection Of Surgical
Procedure For Esophageal
Cancer

2. Introduction: Esophageal Dysplasia
• Dysplasia is a pre-cancerous condition in which the cells lining the
inside of the esophagus look abnormal when seen under a
microscope
• It is sometimes seen in people with a condition called Barrett’s
esophagus
• Dysplasia is graded by how abnormal the cells look under the
microscope
• Low-grade dysplasia
• Looks more like normal cells
• High-grade dysplasia
• More abnormal and is linked to the highest risk of cancer
American Cancer Society. www.cancer.org/

3. Introduction: Esophageal Cancer
• Cancer of the esophagus
• Starts in the inner layer (the mucosa) and grows outward
(through the submucosa and the muscle layer)
• Types
• Squamous cell carcinoma
• 70% in upper & middle third
• Most common worldwide
• Adenocarcinoma
• Distal third
• Most common in Western world
• Rare cancers
American Cancer Society. www.cancer.org/

4. Key Statistics
How Common Is This Cancer?
http://seer.cancer.gov/statfacts/html/esoph.html. Assessed on 12.08.16

5. Key Statistics
Who Dies From This Cancer?
http://seer.cancer.gov/statfacts/html/esoph.html. Assessed on 12.08.16

6. Risk Factors
SCC, Squamous cell carcinoma; ADC, Adenocarcinoma

7. Signs And Symptoms
• Dysphagia (most common); initially for solids, eventually progressing to include liquids
• Weight loss (second most common)
• Bleeding
• Epigastric or retrosternal pain
• Bone pain with metastatic disease
• Hoarseness
• Persistent cough
• Physical findings include the following:
• Typically, normal examination results unless the cancer has metastasized
• Hepatomegaly (from hepatic metastases)
• Lymphadenopathy in the laterocervical or supraclavicular areas (reflecting metastasis)
Baldwin, 2015, www.medscape.com

8. Diagnostic Work Up
NCCN Clinical Practice Guidelines in Oncology, 2016

9. American Joint Cancer Committee/Union for
International Cancer Control/ (AJCC/UICC)
Staging
Baldwin, 2015, www.medscape.com

10. Treatment Of Esophageal Cancer Varies
By Disease Stage
Stage
Stage 1 Consideration for endoscopic therapy (eg, mucosal
resection or
submucosal dissection), particularly for Tis and
T1aN0 by EUS; consideration for initial surgery for
T1b and any N
Stages II-III Consideration for chemoradiation followed by
surgery
(trimodality therapy)
Stage IV Chemotherapy or symptomatic and supportive care
Baldwin, 2015, www.medscape.com

11. Surgical Indications and Contraindications
• Surgical Indications
• Esophageal cancer in a patient who is a candidate for surgery
• High-grade dysplasia in a patient with Barrett esophagus that cannot be
adequately treated endoscopically
• Contraindications to surgery
• Metastasis to N2 nodes (ie, cervical or supraclavicular lymph nodes) or
solid organs (eg, liver, lungs); the treatment of patients with celiac lymph
node involvement remains controversial
• Invasion of adjacent structures (eg, the recurrent laryngeal nerve,
tracheobronchial tree, aorta, pericardium)
Baldwin, 2015, www.medscape.com

12. Primary Treatment For Medically Fit
Patients With Squamous Cell Carcinoma
NCCN Guidelines Version 2.2016
Esophageal and Esophagogastric Junction Cancers
NCCN Clinical Practice Guidelines in Oncology, 2016

13. Primary Treatment For Medically Fit
Patients With Adenocarcinomas
NCCN Guidelines Version 2.2016
Esophageal and Esophagogastric Junction Cancers
NCCN Clinical Practice Guidelines in Oncology, 2016

14. ESMO Guideline
ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up 2013

15. Surgical approaches for esophageal
cancer
• Open esophagectomy (OE)
• Cervical esophagectomy
• McKeownesophagectomy (3-phase esophagectomy)
• Ivor-Lewis esophagectomy (through laparotomy and right thoracotomy)
• Transhiatalesophagectomy without thoracotomy
• Left thoracoabdominalesophagectomy
• Minimally invasive esophagectomy (MIE)
• Total MIE (thoracoscopic and laparoscopic esophagectomy)
• Hybrid MIE (either thoracoscopic or laparoscopic esophagectomy)
• Laparoscopic-assisted transhiatalesophagectomy
• Video-assisted mediastinoscopictranshiatalesophagectomy
• Robot-assisted MIE
Watanabe et al. J Nucl Med Radiat Ther 2012, S:2

16. Choice of technique
• Depends mainly on:
• Tumor Location
• Intended extent of
lymphadenectomy and
reconstructive technique
• Experience and preference of the
surgeon
Watanabe et al. J Nucl Med Radiat Ther 2012, S:2

17. McKeown esophagectomy
(3-phase esophagectomy)
• Subtotal esophagectomy through right thoracotomy with
anastomosis of the cervical esophagus to the stomach brought
to the neck
• Allows the greatest longitudinal and radical margins, permits
complete lymphadenectomy, and minimizes the risk of
intrathoracic leak
Watanabe et al. J Nucl Med Radiat Ther 2012, S:2

18. Transhiatal Esophagectomy
• Stomach mobilized through upper midline laparotomy
• Esophagus is mobilized without a thoracotomy
• Stomach is transposed through the posterior mediastinum and
anastomosed to the cervical esophagus.
• Best for lower esophageal and esophagogastric tumors
• Less likely predisposition to postoperative reflux and recurrent
strictures
Watanabe et al. J Nucl Med Radiat Ther 2012, S:2

19. Ivor Lewis Esophagectomy
• “aka Two-Hole Esophagectomy” (Right thoracotomy and
laparotomy)
• In 1946 Ivor Lewis did a two-stage approach: initial laparotomy
with stomach mobilization followed 10-15 days later by a right
thoractomy, esophagectomy, and esophagogastric anastomosis
• Eventually evolved into a one-stage approach
• Typically used for middle and lower third esophageal tumors
Watanabe et al. J Nucl Med Radiat Ther 2012, S:2

20. Ivor Lewis Esophagectomy
• Advantages:
• An extensive lymphadenectomy can be easily performed through the
right thoracotomy incision
• Direct exposure for dissection of intrathoracic esophagus
• Disadvantages:
• Two major incisions
• Anastomosis in chest
• Complications can be difficult to manage
• Typical leak rates <5%
• Leaks in chest can be more complicated than cervical leaks
Watanabe et al. J Nucl Med Radiat Ther 2012, S:2

21. Left Thoracoabdominal
Esophagogastrectomy
• Used for large GE junction tumors and resection of distal esophagus
and the proximal stomach when removal of the stomach necessitates
an intestinal substitute to restore swallowing
• Also used in very obese patients to facilitate exposure
• Patient placed in right lateral decubitus
• Exlap through oblique incision from tip of 6th costal cartilage to mid
abdomen
• Choice of partial or total gastrectomy
Watanabe et al. J Nucl Med Radiat Ther 2012, S:2

22. Minimally invasive esophagectomy (MIE)
• Improve the postoperative outcomes of esophagectomy
• Several authors have demonstrated that total MIE using a
combined thoracoscopic and laparoscopic approach can be
performed safely
• But the short-term outcome benefits of this approach remain controversial
• Oncologic outcomes are favorable, and MIE may have an
advantage over open esophagectomy in terms of lymph node
dissection
Watanabe et al. J Nucl Med Radiat Ther 2012, S:2

23. Salvage Esophagectomy
• Defined as esophagectomy for remnant or relapsed tumors after
definitive chemoradiotherapy
• Definitive chemoradiotherapy
• 40% to 60% of patients have recurrent locoregional disease
• Major problems with Salvage esophagectomy
• High morbidity and mortality rate
• Anastomotic leakage
• Pulmonary insufficiency
• Hospital mortality ranges from 3% to 22.2%
Therefore, salvage esophagectomy should be considered for
carefully selected patients at specialized centers.
Watanabe et al. J Nucl Med Radiat Ther 2012, S:2

24. Short-term Outcome of Esophagectomy
• Prospective cohort at multiple Veterans Administration hospitals
between 1991 and 2001 demonstrated
• Mortality Rate: 9.8%
• Morbidity Rate 49.5%
• Most frequent postoperative complications were
• Pneumonia (21%)
• Respiratory failure (16%)
• Ventilator support for more than 48 hours (22%).
Watanabe et al. J Nucl Med Radiat Ther 2012, S:2

25. Morbidity and mortality after esophagectomy
with 3-field lymphadenectomy
Cervico-thoraco-abdominal 3-field lymph node dissection is the
most radical lymphadenectomy procedure for esophageal
cancer
It has become a standard surgical procedure in Japan, and has
been adopted in some Western high-volume centers
Watanabe et al. J Nucl Med Radiat Ther 2012, S:2

26. Whether or not MIE improves short-term
outcomes after esophagectomy ?
MIE improves short-term outcomes, especially reduced pulmonary
complications
• According to Fabian T et al, (2008), Schoppmann SF et al (2010), &
Nafteux P et al (2011),
• MIE significantly decreased pulmonary complications compare to open
esophagectomy
• According to Osugi H et (2003), Smithers BM et al (2007), & Mamidanna
R et al (2012)
• Comparable pulmonary morbidity rates between MIE and open
esophagectomy
Further trials are needed
to confirm the result
Watanabe et al. J Nucl Med Radiat Ther 2012, S:2

27. Long-term Outcome of Esophagectomy
Survival results of esophagectomy from large-scale
clinical studies
Although the tumor stage and background factors differed
among patients, long-term outcomes were better in
Japanese studies and in the Japanese registry compared to
the other studies.
Watanabe et al. J Nucl Med Radiat Ther 2012, S:2

28. Long-term Outcome of Esophagectomy
• Finding that outcomes were better in Japan may result from
differences in the quality of lymph node dissection
• 3-field lymphadenectomy is a standard procedure in Japan
• Large-scale prospective randomized trials are required to
provide conclusive evidence
• that differences in outcome are due to differences in the quality of lymph
node dissection
Watanabe et al. J Nucl Med Radiat Ther 2012, S:2

29. Conclusion
• Incidence of Esophageal carcinoma is increasing
• It is essential to recognize and diagnose early
• Surgical resection remains the main treatment for potentially
curable esophageal cancer
• MIE may improve short-term outcome, and 3-field lymph node
dissection may reduce the risk of recurrence.
• The effects of these surgical procedures should be confirmed by
randomized prospective studies

30. Thank You