Evolution of Esophagectomy for Cancer Over 30 Years: Changes in Presentation, Management and Outcomes

Abstract

Background Esophageal cancer has seen a considerable change in management and outcomes over the last 30 years. Historically, the overall prognosis has been regarded as poor; however, the use of multimodal treatment and the integration of enhanced recovery pathways have improved short- and long-term outcomes. Objective The aim of this study was to evaluate the changing trends in presentation, management, and outcomes for patients undergoing surgical treatment for esophageal cancer over 30 years from a single-center, high-volume unit in the UK. Patients and Methods Data from consecutive patients undergoing esophagectomy for cancer (adenocarcinoma or squamous cell carcinoma) between 1989 and 2018 from a single-center, high-volume unit were reviewed. Presentation method, management strategies, and outcomes were evaluated. Patients were grouped into successive 5-year cohorts for comparison and evaluation of changing trends. Results Between 1989 and 2018, 1486 patients underwent esophagectomy for cancer. Median age was 65 years (interquartile range [IQR] 59–71) and 1105 (75%) patients were male. Adenocarcinoma constituted 1105 (75%) patients, and overall median survival was 29 months (IQR 15–68). Patient presentation changed, with epigastric discomfort now the most common presentation (70%). An improvement in mortality from 5 to 2% (p < 0.001) was seen over the time period, and overall survival improved from 22 to 56 months (p < 0.001); however, morbidity increased from 54 to 68% (p = 0.004). Conclusions Long-term outcomes have significantly improved over the 30-year study period. In addition, mortality and length of stay have improved despite an increase in complications. The reasons for this are multifactorial and include the use of perioperative chemo(radio)therapy, the introduction of an enhanced recovery pathway, and improved patient selection.

Technical details for a robot-assisted hand-sewn esophago-gastric anastomosis during minimally invasive Ivor Lewis esophagectomy

“…In the study period, all patients with mid-distal esophagus cancer referred to our center were considered for a minimally invasive Ivor Lewis [16] with the PT. The only exclusion criteria were major vascular involvement, previous major open surgery on the supra-mesocolic area, previous right thoracotomy, and general contraindications to pneumoperitoneum or pneumothorax.…”

ASO Author Reflections: Smoking Status Impact on Perioperative Morbidity and Long-Term Survival of Patients Undergoing Esophagectomy for Cancer

“…Esophagectomy is associated with high levels of morbidity, and smoking is known to increase these risks. 2 However, it is not clear what impact smoking status, with regards to being either a current, ex-, and non-smoker, has on perioperative outcomes and long-term survival.…”

ASO Author Reflections: 30 Years of Esophagectomy

“…It demonstrates a huge improvement in overall survival and correlates this with a number of interventions. 2 Predictably neoadjuvant chemotherapy and chemoradiotherapy have had the biggest impact on long-term survival. However, the implementation of an enhanced recovery pathway has drastically reduced inpatient stay after surgery.…”