Esophageal Surgery

Introduction
We usually perform transthoracic total esophagectomy with mediastinal and cervical lymph node dissection for primary esophageal cancer, when it is considered to be resectable. This is the standard surgery in Japan today, but the patientﾕs physical burden is severe. At surgery, in general, a surgeon from the Head and Neck Division cooperates with us in performing the cervical lymph node dissection.
The prognosis of patients with advanced disease is still poor, though the number of completely curable early cancers has been increasing in recent years.

Routine Activities
The patient data on esophageal cancer are presented at our bi-weekly conferences, attended by medical oncologists, endoscopists, radiologists and thoracic surgeons. In this conference, new cases are clinically staged in detail by image diagnosis. When the lesion is assessed as surgically resectable (stage I to III), staff thoracic surgeons operate on the patient with 1 to 3 residents, in accordance with standard procedures, after obtaining informed consent from the patient. Approximately 20 patients are surgically managed every year. For those with early cancer, who are not assessed as suitable candidates for endoscopic mucosal resection, or who have high-risk conditions, we advocate a transhiatal pull-through esophagectomy or mini-thoracotomy approach assisted with videothoracoscopy.

New Developments
Since patients in the far advanced stage (T4, or M1 LYM in clinical staging) are treated with chemoradiotherapy as a first choice in our hospital, most T4 cases in stage III of the TNM classification are not indicated for surgery. As a result, survival rates in surgical cases are much better than those reported in the literature, as shown in table 2. However, the surgical outcome has been very poor in patients with swelling mediastinal lymph nodes preoperatively detected by CT scan. Therefore, we are attempting neoadjuvant chemoradiotherapy as a pilot study, and there have been 9 patients enrolled into this trial since 1993. Although postoperative morbidity was high in this population, four patients showed pathological CR (complete response), and are expected to be cured and enjoy better survival.
The treatment results of chemoradiotherapy for far advanced cases are generally fair to date, as shown in the report of gastrointestinal oncology, but the prognosis of the T4 cases is particularly poor. As a result, we have started to plan a new protocol for salvage operation of these cases.

Statistics

Number of surgical patients 1992-1997
Year No. of cases

1992 8

1993 21

1994 26

1995 16

1996 20

1997 21

Total 112

Surgical Results in Esophageal Cancer Patients
TNM stage No. of
Cases MST
(Month) Survival rate (%)

1-yr 3-yr 5-yr

Stage I 39 51.1 90.5 77.3 77.3

Stage IIa 8 62.0 100.0 100.0 100.0

Stage Iib 14 50.3 78.6 78.6 78.6

Stage III 24 44.2 68.8 68.8 68.8

Stage IV 7 3.7 0.0 0.0 0.0

Number of surgical patients 1992-1997
Year	No. of cases
1992	8
1993	21
1994	26
1995	16
1996	20
1997	21
Total	112

Surgical Results in Esophageal Cancer Patients
TNM stage	No. of Cases	MST (Month)	Survival rate (%)
1-yr	3-yr	5-yr
Stage I	39	51.1	90.5	77.3	77.3
Stage IIa	8	62.0	100.0	100.0	100.0
Stage Iib	14	50.3	78.6	78.6	78.6
Stage III	24	44.2	68.8	68.8	68.8
Stage IV	7	3.7	0.0	0.0	0.0

(M. Nishimura)

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