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382 Part III Esophagus
have been developed to seal esophagoairway stulae and prevent tumor ingrowth. ree randomized trials were reported
comparing the use of metallic stents with plastic prostheses.
Perforation, pneumonia, bleeding, or migration rates were
signicantly less with metallic stents. Because of the lower
morbidity, metallic stents were also more cost-eective
288–290
despite their higher initial cost.
e choice of various
metallic stents depends on their individual characteristics, in
terms of exibility, tensile force, and degree of shortening on
deployment in relation to the site of placement. Compared
with more conventional methods of palliation such as laser
therapy, patients with SEMS spent less time in the hospital
and required less frequent reinterventions.
291
e main problems with SEMS are stent migration, tumor
ingrowth or overgrowth, and, if placed across the GEJ, they
allow acid reux. Placing uncovered stents across the cardia
lessens the chance of migration, and stents have been devel-
292
oped with a one-way ap valve to prevent reux.
It has
also been shown that “tumor” ingrowth is sometimes due to
granulation tissue or hyperplastic reaction by the esophageal
293
mucosa.
Patency can be achieved again by laser, argon beam
application, or sometimes placement of a second stent within
the rst. One recent randomized trial compared the use of
the Ultraex stent (Boston Scientic, MA) with the Polyex
stent (Boston Scientic, MA), and the Niti-S double stent
(Taewoong Medical, Seoul, Korea). e Polyex stent is a silicone device with an encapsulated monolament braid made
of polyester. e silicone and polyester material is designed
to lessen nontumoral tissue overgrowth, a problem common
with SEMS. e Niti-S stent has an inner polyurethane layer
over its entire length, and an outer uncovered nitinol wire
tube to allow the mesh to embed itself in the esophageal
wall. Success rates were similar for all three stents, but recurrent dysphagia was more common with the Ultraex stent,
because of tissue ingrowth and overgrowth, and, to lesser
degree, the Niti-S stent. Polyex stent had a higher chance of
migration, not surprisingly, because the stent is also designed
to be removable in benign esophageal stenosis.
294
Another problem of stent insertion is for placement near to
the upper esophageal sphincter. Foreign body sensation, pain,
odynophagia, and airway compression can be troublesome
and demand accurate placement. is is illustrated in the situation when recurrent disease is found at the anastomosis or in
the esophageal remnant after subtotal esophagectomy. Placement of SEMS is still possible and achieves good palliation.
295
SUMMARY AND
FUTURE PERSPECTIVES
Advances have been made in the management of esophageal
cancer; survival of patients has improved.
the most appropriate combination for individual patients.
Surgeons play a central role in directing management treatment
of this disease by advising on how best to integrate surgical resection with nonoperative programs. Surgeons should
aim at improving their results further, so that low mortality
296
e key is to select
rates for resections are used to compare with seemingly safer
therapies. e technique and extent of surgical resection may
change when more information is made available, and should
vary with patients and disease stage. MIE will be more widely
practiced; it should achieve the same radicality of operation
with less morbidity. Chemoradiation therapy has made a real
296
impact on current management strategies,
but perhaps its
overenthusiastic adoption and its presumed benet have to be
balanced against the lack of clear evidence of superiority over
297
surgery.
Distant failure remains a major problem, and search
for more eective systemic drugs as well as our ability to predict
responders with precision must be therapeutic targets. Management strategies are going to evolve further, with improvements
in molecular techniques, imaging methods, and introduction
of more novel tumoricidal agents. e challenge for the future
is for us to critically test our strategies in a scientic, unbiased
manner, and to explore other innovative treatments.
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SURGICAL PROCEDURES TO RESECT AND REPLACE THE ESOPHAGUS
Jon O. Wee • David J. Sugarbaker
18
Billroth and Czerny described the rst esophageal resections
in the 1870s, and they consisted of resections of the cervical esophagus without reconstruction. Later, resection of
gastroesophageal (GE) junction tumors was performed by
laparotomy with gastroesophageal anastomosis to reestablish intestinal continuity. Because there were concerns over
respiratory compromise, surgeons were hesitant to enter
the chest to perform esophageal resection. In 1915, Torek
described the rst transthoracic esophageal resection.
used a left thoracotomy to resect the esophagus but did not
attempt reconstruction. Instead, a cervical esophagostomy
and abdominal gastrostomy were performed. A 3-ft-long
external rubber tube was used to connect the ostomies, and
it allowed the patient to eat for 17 more years ( Fig. 18-1 ).
Turner performed the rst transhiatal esophagectomy in
2
Oshawa reported the rst transthoracic resection of
1933.
the esophagus with esophagogastric anastomosis in 1933.
Knowledge of this procedure did not become widespread
in the Western community until Adams and Phemister
described the procedure in 1938.
Ivor Lewis is credited with popularizing transthoracic resection of the esophagus. Initially, he performed the procedure in
two stages: rst, mobilizing the stomach via laparotomy and
several days later resecting the intrathoracic esophagus and
reconstructing with the stomach. e Ivor Lewis approach,
which is an upper midline laparotomy for mobilization of the
gastric conduit followed by right thoracotomy for resection
and reconstruction, and the transhiatal approach are currently
the two most commonly used techniques of esophageal resection. In 1962, McKeown described a tri-incisional approach.
He used a right thoracotomy to mobilize the esophagus. e
patient was then repositioned in the supine position, the gastric conduit was mobilized by laparotomy, and the anastomosis was performed in the neck.
for surgical resection have also become increasingly popular.
Combined thoracoscopic and laparoscopic techniques in
some combination with open techniques have created a wider
hybrid experience and are discussed in other chapters.
4
5
Minimally invasive options
1
He
3
6,
7
NEOADJUVANT TREATMENT
Historically, surgery has been the primary mode of treatment for localized esophageal cancer. Nonetheless, the
long-term results of surgery alone for esophageal cancer are
disappointing.
posed as a means of improving long-term survival. Eight
randomized trials have been performed using preoperative
chemoradiation. Although the two largest randomized trials
comparing preoperative chemoradiation followed by surgery
to surgery alone showed no di erence in survival,
smaller randomized trials have been used to support the use
of preoperative chemoradiation. Urba and colleagues looked
at 100 total patients randomized to preoperative chemoradiation or surgery alone.
months in both groups, although there was a trend toward
improved survival at 3 years (30 vs 16%; not statistically
signi cant). Walsh and associates randomized 113 patients,
and at 3 years 32% of those receiving preoperative chemoradiation were alive versus 6% of those undergoing surgery
12
alone.
lack of adequate pretreatment staging as well as a very poor
survival in the surgical arm that is far below all other reported
series. Hence, although there are no de nitive data to support
the use of chemotherapy and radiation in the neoadjuvant
setting, it remains widely used.
CALGB 9781 (Cancer and Leukemia Group B 9781)
was a prospective randomized intergroup trial that evaluated patients with stages 1–3 esophageal cancer. Patients were
randomized to surgery alone or to preoperative cisplatin and
5-FU with concurrent radiation (50.4 Gy) followed by surgery. Poor accrual resulted in premature closure of the study
with 56 patients, well short of its goal of 500 patients. Nonetheless, with median follow-up of 6 years, 5-year survival was
39% for the trimodality group versus 16% for the surgeryalone group. Median survival was 4.5 years for the trimodality group versus 1.8 years for the surgery-alone group
(p = .02).
8
Preoperative chemoradiation has been pro-
11
Median survival was about 18
is study, however, has been heavily criticized for its
13
A meta-analysis by Urschel and Vasan in 2003
9,
10 two
389
390 Part III Esophagus
A
FIGURE 18-1 A. Depiction of Torek’s rst patient after esophageal resection. e rubber tube connected the lower end of the esophagus with a
gastrostomy. e patient lived 17 years after the surgery and died at age 80. B. Removable rubber tube conduit with beveled ends. (
permission, from Torek F. e operative treatment of carcinoma of the esophagus. Ann Surg 1915;61:385.)
combined the results of over 1100 patients from nine randomized controlled studies comparing neoadjuvant chemo-
B
Reproduced, with
adenocarcinoma, and the regional practice patterns make a
large, randomized study dicult to envision.
radiotherapy followed by surgery versus surgery alone. is
study did favor neoadjuvant chemoradiotherapy with surgery
over surgery alone.
14
STAGING
ere is substantial comparative evidence of the benet
of neoadjuvant chemotherapy for locally advanced esophageal cancer. e MRC (Medical Research Council) trial of
2002 demonstrated a statistically signicant survival benet
(43 vs 34%) in those patients who received preoperative chemotherapy with an increase in median survival from 13.3
15
to 16.8 months.
is report was followed by the MAGIC
(Medical Research Council Adjuvant Gastric Infusional Chemotherapy) trial in 2006, which further demonstrated an
improved survival in patients with GE junction adenocarcinoma at 2 years (50 vs 41%) and at 5 years (36 vs 23%).
A head- to-head comparison of neoadjuvant chemotherapy
versus neoadjuvant chemoradiotherapy by the German
Esophageal Cancer Study Group did not demonstrate any
improved ability to achieve R0 resection with the addition
17
of x-ray therapy (XRT).
e study was underpowered, but
there was a trend toward increased mortality in the radiation
arm. Paradoxically, there also was a trend toward improved
survival with the addition of radiation, although this nding was not statistically signicant. Unfortunately, no clear
determination was made regarding which method is better.
e relatively low incidence of esophageal cancer, the variable
response to treatment between squamous cell carcinoma and
It is important to recognize those patients with stage IV
disease because the mean survival in these patients is 6–10
months. In the past, palliative esophagectomy was often
thought necessary to restore swallowing and oral nutrition.
With advances in photodynamic therapy, expandable endoscopic stents, and other endoluminal therapies, it is unusual
for anyone to require esophageal replacement to reestablish
swallowing ability. Hence, stage IV patients should be spared
the perioperative mortality, morbidity, and recovery time
16
associated with esophagectomy. e appropriate use of neoadjuvant treatment requires accurate staging. Patients with
nodal involvement, invasion through the esophagus, or possibly even invasion into the muscularis often undergo preoperative chemoradiation, while patients with simple mucosal
involvement generally proceed directly to surgery.
e main staging modalities available today are computed tomography (CT) scan, positron emission tomography
(PET) scan, and endoscopic ultrasound (EUS). CT scans are
used mainly for detecting distant metastases in the lungs,
liver, or other remote sites, including the brain. CT scan may
be useful for excluding T4 tumors if a fat plane can be demonstrated between the adjacent structure and the esophagus.
Chapter 18 Surgical Procedures to Resect and Replace the Esophagus 391
Such staging is often not possible if the patient is severely
cachectic or if there are no natural fat planes, such as that
between the trachea and esophagus. In regard to nodal status,
CT is not as sensitive or as accurate as EUS.
PET scan is superior to CT scan for detecting distant
metastatic disease. In a series of 91 patients, CT scan had a
sensitivity of 46%, a specicity of 74%, and an overall accuracy of 73%. In contrast, PET scan had a sensitivity of 69%,
specicity of 93%, and overall accuracy of 84%. All metastases that were missed by PET were less than 1 cm in size.
18,19
Other studies have shown similar results.
In addition,
7
PET scan may aid in the diagnosis of primary tumor where
it may be dicult to perform biopsy because of obstruction.
Conversely, a certain percentage of nonbulky tumors of the
esophagus may be PET-negative.
EUS gives detailed images of the esophageal wall and
nearby structures (Fig. 18-2). Accurate identication of the
layers of the esophageal wall is possible. Muscle layers tend
to be hypoechoic with intervening hyperechoic mucosal
layers. e rst hyperechoic layer and second hypoechoic
layer correspond to the mucosa and muscularis mucosa. e
third hyperechoic layer is submucosa. e fourth hypoechoic
layer is the muscularis propria, and the fth hyperechoic
layer is the outside of the esophagus. Tumor inltration of
the wall disrupts the normal-layered appearance, and extent
of penetration is usually clearly visible. EUS has an overall
accuracy of 80–90% in ascertaining T status. e dierentiation between T1 and T2 is most dicult. In addition,
biopsy of deeper layers of tumor not accessible by traditional
grasping forceps is possible. It should be noted that EUS is
not accurate in dening postneoadjuvant treatment T status
because of brosis induced by the chemoradiation.
Nodal status is determined by examining four characteristics. Malignant nodes tend to be round and hypoechoic.
ey have discrete borders and are larger than 1 cm in size.
Nodes that meet such criteria have a 90% chance of being
malignant. Fine-needle aspiration (FNA) further increases
the accuracy in determining nodal status. If the tumor is from
a node, the cytopathologist should be able to identify lymphoid tissue in the specimen. False positives can result with
FNA if the needle passes through the primary tumor. e
accuracy of EUS in N-status staging is between 70 and 80%.
EUS is 10–15% more accurate than CT scan.
20
Developments in EUS and PET scanning have lessened the
enthusiasm for pre-resection operative staging of esophageal
cancer patients. Operative staging involving laparoscopy and
thoracoscopy is more invasive but may be superior to EUS.
Luketich and associates studied 26 patients and detected N1
disease in a considerable number of patients staged NO by
21
It should be noted, however, that the sensitivity of
EUS.
EUS in this series was only 60%, considerably lower than that
described in other series. In addition, 15% of patients with
no radiographic metastatic disease were found to have liver
metastases by laparoscopic staging. e average cost of surgical staging was $20,000–$25,000 versus $2000 for EUS.
A common algorithm used in staging patients includes
endoscopy for primary diagnosis, CT scanning with PET to
evaluate for metastatic disease, and EUS if the patient is an
operative candidate and neoadjuvant therapy is considered.
In cases of esophageal obstruction, where EUS scanning
is known to be less accurate, the incidence of lymph node
metastasis is very high (90%) and neoadjuvant therapy should
be considered.
FIGURE 18-2 Endoesophageal ultrasound image of an adenocar-
cinoma of the esophagus (T3) and multiple lymph nodes suspicious
for metastatic disease (N1).
J, Sivak MV, Catalano MF, et al. High-grade malignant stricture is predictive of
esophageal tumor stage: risks of endosonographic evaluation. Cancer. 1993;May 15:
71(10):2910–2917.)
(Reproduced with permission from Van Dam
APPROACH TO THE CERVICAL LESION
e treatment of a cancer of the cervical esophagus is challenging and requires a multidisciplinary approach involving
an otorhinolaryngologist, a thoracic surgeon, and occasionally a plastic surgeon. Frequently, radiation will be required
preoperatively to maximize margins and spare the larynx, if
possible. e neck incision is made along the anterior border
of the sternocleidomastoid muscle and can be extended across
the midline if additional exposure is needed. If the tumor is
xed to the spine or neck vessels, the procedure is aborted and
palliative radiotherapy is considered. If the larynx is involved,
it is removed en bloc with the upper esophagus along with
the upper paraesophageal nodes bilaterally. A radical neck dissection is not routinely performed. e dissection spares the
jugular vein, sternocleidomastoid muscles, and spinal accessory nerves. e trachea is transected, leaving enough length
to allow construction of a permanent end tracheostomy.
e endotracheal tube is inserted into the distal trachea and
thehypopharynx is divided sharply.