A personal perspective on controversies in the surgical management of oesophageal cancer

Abstract

Significant disagreement and debate persist regarding several aspects of the optimal surgical management of oesophageal cancer. We address some of these issues based on our consecutive series of 165 patients undergoing oesophageal resection (reported in full elsewhere) and the available literature. The areas considered are controversial but we argue in favour of a 'traditional' two-stage open approach (Ivor-Lewis), leaving the pylorus alone, making no attempt to perform a radical lymphadenectomy and fashioning a hand sewn anastomosis. KEYWORDSOesophagectomy -Ivor-Lewis -Oesophageal cancer -Gastro-oesophageal anastomosisPyloroplasty -Lymphadenectomy The aim of this paper is to outline and justify the approach we favour for oesophageal resection in malignant disease. In order to accomplish this aim, we draw on our own experience 1 and review of the relevant literature. Surgical approachPerhaps because the oesophagus is present in the neck, the thorax and the abdomen, multiple surgical approaches (and combination of approaches) to oesophageal resection are described. Inevitably, there is controversy over the optimal approach. We favour a laparotomy and right lateral thoracotomy. This is preferred to other approaches such as a threestage, transhiatal or minimally invasive oesophagectomy (MIO).In the three-stage (McKeown) approach, gastro-oesophagectomy is followed by a further cervical incision and an anastomosis fashioned in the neck. We are unable to identify any compelling argument to support this approach. It is claimed that anastomosis is technically easier in the neck than in the chest. In south Wales, the majority of patients with oesophageal cancer are overweight with a barrel chest and a short neck. In our experience, no matter how high in the chest it located, an intrathoracic anastomosis is unarguably technically easier than in the neck.It is also argued that anastomotic leakage following cervical anastomosis is less dangerous than in the chest. Not all oesophageal surgeons accept this. There is evidence that a cervical anastomosis often comes to lie in the upper part of the thoracic cavity.2 Since our rate of anastomotic leakage is, fortunately, very low (overall leak rate 1.2%, clinical leak rate 0.6%), this is not an issue in our practice.A further potential argument in favour of the three-stage approach is a greater proximal resection margin; the advantage has been estimated at 1cm.2 No patient in our series had an involved proximal margin, which suggests that adequate clearance can be obtained with an intrathoracic approach. The majority of the available evidence suggests that the rate of benign anastomotic stricture is significantly lower in intrathoracic than in cervical anastomoses.3-5 (See 'Anastomotic technique' section below.) We can identify no advantages to a three-stage procedure. In our series of 165 patients, access to the neck was needed in only two patients who developed significant complications. It is claimed that a transhiatal approach to oesophageal resection is associated wi...

Esophageal anastomosis - how the granulation phase of wound healing improves the incidence of anastomotic leakage

“…Intrathoracic anastomosis performed in mid-esophageal lesions is not free of the risk of cancer-positive resections margins (25). Certain studies have emphasized that R0 resection in particular has an impact on survival rate (26). None of the patients in the present study that underwent anastomosis on the neck after subtotal esophagectomy were positive for cancer within the resection margin.…”

Trans-thoracic versus trans-hiatal resection for oesophageal carcinoma: a retrospective comparative study of a single-centre case series

“…Rindani et al [35] found a stricture rate of 28% among patients in the THE group vs. 16% among patients in the TTE group and Liu et al found a stricture rate of 19.8% among patients in the THE group vs. 13.5% among patients in the TTE group [35]. Gastric conduit ischaemia with subsequent post-operative anastomotic leaks, stapled anastomosis, cardiovascular diseases and COAD were identified as risk factors [24,31,33,36,37].…”

“…Although the initial results were promising, with a comparable outcome to open resection, avoiding thoracotomy will further reduce pulmonary complications associated with an open approach, and better visual control allows favourable oncological quality of resection. However, there is still no convincing evidence that MIE is superior to open oesophagectomy [24].…”

The influence of minimally invasive esophagectomy on wound infection in patients undergoing esophageal cancer surgery: A meta‐analysis

“…18,19 However, ESCA has a high rate of lymphatic metastasis, and whether MIE is beneficial to the prognosis and long-term survival of patients with advanced ESCA has not been confirmed; meanwhile, Markar et al 20 found that in some cases, the short-term outcome of MIE was worse compared with OE, so some scholars are currently doubtful whether MIE is superior to OE. 21,22 Therefore, the aim of this study is to compare the effects of MIE and OE on postoperative complications, wound infection and hospital stay in ESCA patients through meta-analysis, so as to provide a theoretical basis for the selection of the best surgical method for ESCA patients.…”