Chapter 19: Radical En Bloc Esophagectomy

INTRODUCTION

Despite improvements in perioperative care, surgical techniques, and neoadjuvant therapy over the past decade, the prognosis of esophageal cancer remains poor. More than 95% of new patients 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 Although the addition of preoperative therapy may reduce rates of local failure and improve survival (Cross trial), a meaningful improvement in the survival of patients with esophageal cancer is unlikely without adequate surgical resection of the primary disease.

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 in order to obtain an adequate circumferential margin (CRM). Currently, there are two definitions of a positive esophageal CRM. The College of American Pathologists (CAP) defined a positive CRM as tumor at the cut margin of resection. On the other hand, the Royal College of Pathologists (RCP) considers that a positive CRM indicates that tumor is present at or within 1 mm of the margin of the lateral surface of resection. Most, though not all, studies examining the impact of CRM on outcome applied the definition of the RCP. Although definitive prospective data are lacking, the importance of the radial, or CRM, has also been described.^12–15 The first large-scale study on the topic was by Dexter et al., who reported on 135 esophageal cancer patients treated by “curative” esophagectomy, most commonly performed using a transthoracic approach.¹⁴ Surprisingly, the authors found that 47% of patients who had a presumed R0 ...