Esophageal Surgery
Introduction
We usually perform transthoracic total esophagectomy with mediastinal and cervical lymph node dissection for resectable primary esophageal cancer. This is the standard surgical intervention for the disease in Japan, but the physical burden on patients 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, although the number of curable early cancer patients has been increasing in recent years.
Routine Activities
Approximately 20 esophageal cancer patients are treated at our Division each year. Medical records, in particular the findings of image diagnosis (CT, endoscopy, etc.) in all of the patients are discussed preoperatively at a biweekly conference on esophageal cancer, consisting of medical oncologists, endoscopists, radiologists and thoracic surgeons. A staff thoracic surgeon and 1 to 3 residents manage the patients with resectable primary esophageal cancer in Stages I to III. For early stage cancer patients, who are not candidates for endoscopic mucosal resection, or those at high-risk for regional lymph node metastasis, we perform transhiatal pull-through esophagectomy or video-thoracoscopy assisted by a mini-thoracotomy approach.
As the surgical outcome has been very miserable in patients who have mediastinal lymph node swelling detectable by CT, we attempted to carried out preoperative chemoradiotherapy as a clinical trial, and 9 patients were enrolled in this study, between the period of 1993 and the beginning of 1998. Of the 9 patients, 4 showed pathological CR and are expected to enjoy better survival. In spite of this, because of the excessive morbidity and mortality in this population, we terminated the study.
New Developments
Protocol study involving surgical resection was not carried out this year. For deeper invasive early cancer patients, however, we attempt to carry out hand-assisted thoracoscopic esophagectomy, employing a video-thoracoscope with only three thoracoports (one for scope insertion, another for surgical manipulation, and one for retraction). The operator inserted his left hand into the right thoracic cavity through the retrosternal space, which is approached from an 8-cm upper abdominal incision without opening the abdominal cavity. The operator's left hand retracts the right lung toward the anterior side of the patient for esophagectomy. Thoracic esophagectomy and systematic mediastinal lymph node dissection are accomplished by this technique in a similar manner to the usual procedure.
Statistics
| TNM stage | Pts |
| I | 9 |
| IIa | 4 |
| IIb | 3 |
| III | 4 |
| Total | 20 |
| TNM stage | Cumulative survival rate (%) |
| I | 73 |
| IIa | 70 |
| IIb | 63 |
| III | 49 |
| IV | 50 |
(M. Nishimura)
