19: Radical En Bloc Esophagectomy

Introduction

Despite improvements in perioperative care, surgical techniques, and neoadjuvant therapy over the last decade, the prognosis of esophageal cancer remains poor. More than 95% of new cases diagnosed annually in the United States succumb to disease. Among the subset of patients resected with curative intent (R0 resection), the 5-year survival after transthoracic esophagectomy or transhiatal esophagectomy rarely exceeds 30% based on reports from large surgical series.^1-4 The principal justification for these poor results is the finding that most patients develop metastatic disease and already may have disseminated disease at the time of diagnosis. A careful analysis of the patterns of failure after surgical resection also implicates inadequate locoregional control. The locoregional failure rates are unacceptably high after conventional surgical resection, ranging from 30% to 60%.^5-8 The addition of preoperative therapy of any kind does not meaningfully reduce the high rate of local failure.^6-8 Thus a meaningful improvement in the survival of patients with esophageal cancer is unlikely without adequate locoregional control.

En bloc resection for tumor of the lower esophagus and cardia was first described by Logan in 1963.⁹ The reported 5-year survival was unparalleled at the time but was achieved at the cost of high operative mortality. In 1979, Skinner revisited the en bloc approach and extended its use to tumors of the middle and proximal esophagus, publishing his first report in 1983.¹⁰ A few years earlier, Orringer and Sloan¹¹ published their first report on the transhiatal approach for esophagectomy without thoracotomy. The controversy continues to the present concerning the efficacy of radical en bloc esophagectomy, and most surgeons favor conventional techniques of esophageal resection through either a transthoracic or a transhiatal approach. However, we and others continue to advocate radical en bloc esophageal resection as the optimal procedure for maximizing locoregional control and improving long-term survival in patients with esophageal cancer.¹² The basic concept of en bloc esophagectomy is resection of the tumor-bearing esophagus with a wide margin of surrounding tissues. Thus, for tumors of the middle or lower thoracic esophagus, the en bloc specimen includes the tumor-bearing esophagus, the pericardium anteriorly, both pleural surfaces laterally, and the thoracic duct and all other lymphoareolar tissue wedged posteriorly between the esophagus and the spine. The associated lymphadenectomy includes en bloc resection of all nodal groups in the middle and lower mediastinum as well as the upper abdomen.

For a selected group of patients, the lymphadenectomy is extended to include the superior mediastinal and cervical lymph nodes (three-field lymph node dissection). The three-field concept was first introduced by Japanese surgeons, prompted by their observation that up to 40% of patients resected by radical two-field esophagectomy developed isolated recurrences in the cervical nodes.¹³ In 1991, Isono et al.¹⁴ reported nationwide results of three-field lymph node dissection and found that occult cervical node metastases occurred in one-third of patients. Even for lower-third tumors, ...