Esophageal Surgery

Introduction

The Esophageal Surgery Division deals with neoplasms arising from the esophagus. The surgical management of esophageal cancer has been the main clinical as well as research activity of this Division. In particular, with regard to surgery for esophageal cancer, since transthoracic esophagectomy with 3-field lymphadenectomy has become more safe, reliable, and radical, the Division is striving to improve the surgical procedure further in order to decrease the high incidence of postoperative mortality and morbidity that occur following this procedure. The Division is conducting a study to define the role of surgery in the multimodal approach to the treatment of esophageal cancer.

Routine Activities

The Esophageal Surgery Division consists of 2 staff surgeons and 1 resident. An Esophageal Conference is held every Tuesday evening to discuss the diagnosis, staging, and treatment strategy for each patient and is attended by surgeons, medical oncologists, endoscopists, radiologists, radiation oncologists, and head & neck surgeons. Approximately 2 patients are operated upon every week. In 2007, 88 patients underwent esophagectomy. Transthoracic esophagectomy with extended lymph node dissection was performed on 67 nontreated cases before surgery, and modified transthoracic esophagectomy was performed as a salvage procedure in 21 patients in whom other therapeutic modalities had failed. Postoperatively, within 30 days, 2 patients died due to tracheal necrosis. Recently, salvage esophagectomy has been demonstrated to be a safe and reliable surgical procedure for treating residual or recurrent tumors in cases where other therapeutic modalities have failed.

Clinical Activities

The prognosis of patients with intramural metastasis (IMM) or with involvement of >4 lymph nodes is very poor as compared to the patients who do not have these factors. The Division is examining the role of pre- or postoperative chemotherapy in patients who had these factors. These patients are administered 2 cycles of pre- or postoperative chemotherapy with 5-fluorouracil and cisplatin.
Patients with stage II/III esophageal cancer are administered preoperative chemotherapy with cisplatin and 5-fluorouracil according to the outcome of the JCOG 9907 study.
For treating patients aged >80 years who are unable to receive definitive chemoradiotherapy or undergo surgery, transhiatal esophagectomy with upper and middle to lower mediastinal lymph node dissection up to as much extent as possible is being attempted.
Since 2000, the Division has started to perform salvage surgery for patients in whom definitive chemoradiotherapy has failed. The operative procedures and postoperative management have been refined gradually. The Division is also studying the role and efficacy of salvage surgery in the multimodal treatment of esophageal cancer.
JCOG trial 0502: This is a randomized controlled trial of esophagectomy versus chemoradiotherapy in patients with clinical stage I esophageal carcinoma.

● H. Daiko ●

Table 1. Number of Patients
Squamous cell carcinoma 77
Adenocarcinoma 3
Carcinosarcoma 3
Undifferentiated 4
Total 88

Table 2. Type of Procedure
RT. Thoracotomy with 3-field 62
Transhiatal esophagectomy 6
Salvage esophagectomy 21
Total 88

Table 3. Clinical Staging of Nontreated Cases
Stage I 11
IIA 29
IIB 4
III 23
IV 3

Table 4. Postoperative morbidity and mortality
  No. of patients (%)
Recurrent nerve paralysis 10 (11)
Leakage 7 (8)
Wound infection 5 (6)
Pneumonia 2 (2)
Chylothorax 2 (2)
Others 3 (3)
Death within 30 days postoperatively 2 (2)

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