Esophageal Surgery

Introduction
We usually perform transthoracic total esophagectomy with mediastinal and cervical lymph node issection for resectable primary esophageal cancer. This is the standard surgical intervention for the disease in Japan, but the physical burden is severe on patients. At surgery, in general, a surgeon from the Head and Neck vision 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 the recent years.

Routine Activities　
Approximately 20 esophageal cancer patients are surgically managed every year. Recently, esophageal cancer patients are increasing in number in our hospital. All patients are presented at our bi-weekly conference held on Tuesday evening. The conference consists of medical oncologists, endoscopists, radiologists and thoracic surgeons. A staff thoracic surgeon and 1 to 3 residents manage patients with primary esophageal cancer,ssessed as surgically resectable preoperatively (clinical stage I to III). In early stage cancer patients who are not candidates for endoscopic mucosal resection, or in high-risk patients, we perform transhiatal pull-through esopha-gectomy or video-thoracoscopy assisted, mini-thoracotomy approach. In patients with CT-detectable mediastinal lymph node swelling, the surgical outcome has been very miserable. Therefore, we are attempting preoperative chemo-radiotherapy as a clinical trial. Postoperative morbidity was high in those treated. Nevertheless, pathological CR patients were expected to enjoy better survival. Due to the excessive morbidity and mortality, however, we closed this study, after all.

New Developments
Protocol studies of surgical resection have been on going in the NCCHE. One of them is a multiinstitutional randomized controlled trial, designed to compare the efficacy of preoperative neoadjuvant chemotherapy with that of postoperative adjuvant chemotherapy (JCOG9907).
For high-risk patients and early cancer patients, we attempted to perform hand-assisted thoracoscopic esophagectomy in order to avoid the complications by thoracotomy and laparotomy. We perform surgical manipulations in the thoracic cavity through only three thoracoports. Outline of the technique is as follows; under videothoracoscopy the operator inserted his left hand into the right thoracic cavity via retro-sternal space through a mid upper abdominal incision, which is not for opening the abdominal cavity but for approaching to the thoracic cavity. Then thoraco-scopic esophagectomy is carried out with assistance of his left hand inserted.This technique enables easy and accurate minimal surgery.
We applied median sterunotomy approach for upper thoracic esophageal cancer. Lung cancer patients are usually performed of operation by this technique. From the year of 2001, we started salvage surgery of post chemoradiation patients. All patients were reconstructed by right colon conduit with supercharged at the neck. There was no operative death up to the present.

M. NISHIMURA

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