The American Cancer Society’s estimates for esophageal cancer in the United States for 2018 are about 17,290 new esophageal cancer cases diagnosed (13,480 in men and 3810 in women). 15,850 deaths occurred from esophageal cancer (12,850 in men and 3000 in women).1 Esophageal cancer is more common among men than among women.2,3 The lifetime risk of esophageal cancer in the United States is about 1 in 132 in men and about 1 in 455 in women. Overall, the rates of esophageal cancer in the United States have been fairly stable for many years, but over the past decade they have been decreasing slightly. Adenocarcinoma is the most common type of cancer of the esophagus among Whites, while squamous cell carcinoma is more common in African Americans. American Indian/Alaska Natives and Hispanics have lower rates of esophageal cancer, followed by Asians/Pacific Islanders.
Esophageal cancer makes up about 1% of all cancers diagnosed in the United States, but it is much more common in some other parts of the world, such as Iran, northern China, India, and southern Africa.
Despite advances in chemotherapeutic agents and radiation therapy, surgery remains the core component of treatment of this disease. Especially in early-stage disease, surgery is still offered as definitive therapy. Adenocarcinoma of the esophagus develops predominantly in a segment of intestinal metaplasia, and thus the increased incidence of esophageal adenocarcinoma translates into an increasingly prevalent disease in the distal third of the esophagus.4 Given the anatomic configuration of the esophagus within the thoracic cavity, no one surgical incision provides uniform access to the entire esophagus. The surgical approach therefore must be tailored to the individual patient, permitting adequate exposure to the diseased region of the esophagus with the least amount of invasiveness.
Although resection of the distal esophagus via a left transthoracic incision was first described in the 1930s, the increasing prevalence of distal esophageal cancer has renewed interest in this surgical approach. Likewise, for Barrett esophagus and high-grade dysplasia, the left transthoracic approach can be optimal, allowing a safe and complete resection through a single incision with much shorter operating times.5
PARTICULARITIES WITH THIS APPROACH
The advantage of left transthoracic esophagectomy is readily apparent in that it affords a surgical resection with a single incision. In addition to the obvious advantage of decreasing the patient’s discomfort, the left transthoracic esophagectomy also can be performed in much less time than the Ivor Lewis or McKeown esophagectomy, with operative time averaging 2 to 3 hours.6 The left transthoracic approach does have a number of disadvantages that should be noted. First, although the division of the diaphragm provides excellent visualization of the left upper quadrant of the abdomen via the left chest, the remainder of the abdomen cannot be accessed using this approach. As a result of the limited abdominal exposure, adequate dissection ...