Right Compared With Left Thoracic Approach Esophagectomy for Patients With Middle Esophageal Squamous Cell Carcinoma

Abstract

Background: In China, open surgical approaches for esophageal cancer (EC) can be divided into two techniques, the right-and left-transthoracic esophagectomy. Although there is an increasing number of instances that use the right side, the optimal surgical technique remains unclear. Based in a large cancer center with rich experience of both transthoracic side approaches, this study compared the long-term survival of patients treated by these two surgical techniques. Methods: The patients included in this study underwent a right transthoracic esophagectomy (Right, McKeown) or left transthoracic esophagectomy (Left, Sweet, or chest neck dual-incision) for esophageal squamous cell carcinoma (ESCC) between January 2015 and October 2018. The overall survival(OS) rate and perioperative data between the two groups were then retrospectively analyzed. Results: We included 437 patients who underwent Right (n = 202) and Left (n = 235) approaches for ESCC. There was a significantly longer median operative time (250 vs. 190 min, P < 0.001) and longer median postoperative hospital stay (17 vs. 14 days, P < 0.001) in the Right side group. The OS at 5-years was 49.9% in the Right group and 52.45% in the Left group; hazard ratio (HR) (95% CI): 1.002 (0.752-1.337), p = 0.987. Conclusions: For middle thoracic ESCC without suspected lymph node metastasis in the upper mediastinum, the esophagectomy through the Left thoracic approach could achieve the same OS as the Right side, with better short-term outcomes.

Effect of different surgical approaches on the prognosis of patients with postoperative radiotherapy for stage IIB–IVA esophageal squamous cancer

“…Although right thoracic esophagectomy is more effective than left thoracic esophagectomy for lymph node dissection for esophageal cancer [21][22][23], there is no prospective study evidence whether patients really benefit from radical lymph node dissection and the optimal extent of lymph node removal during esophagectomy still remains unclear [24,25]. Two studies from Sweden and the United Kingdom showed that intraoperative lymph node dissection for esophageal cancer had no significant effect on the survival and prognosis of patients with esophageal cancer [26,27].…”

Improvement in the Prognosis of Esophageal Cancer Patients Treated by Surgery Alone (the Sweet Approach) in a High Volume Center Between 1970 and 2008 - A Retrospective Analysis of 5349 Cases

“…These advantages are supported by solid evidence from large surgical cohorts in northern central China. [18][19][20][21] In fact for operations as traumatic as transthoracic resection of esophageal cancer with 2 or 3 eld lymphadenectomy, surgical complication or postoperative morbidity also affect postoperative survival. [22] In a multivariate Cox regression analysis of 419 esophageal cancer cases resected at Keio University Medical School Hospital of Japan, Ando reported that among the seven signi cant independent prognostic factors including gender, surgical year (1981-1987 vs. 1988-1995), depth of tumor invasion (T1b/T2/T3/T4), lymph node metastasis (N0/N1-3/N4-6/N7-), degree of residual tumor (R0/R1,R2), postoperative complication (none/non-lethal complication/lethal complication) and number of dissected mediastinal nodes, the effect of postoperative complication was the largest and was identical to that of lymph node metastasis (Relative risk and 95% CI 2.23 (1.78-2.80), P<0.0001 and 1.59 (1.34-1.89), P<0.0001 respectively).…”

“…[24]However, a recent study in a high volume center (Henan Cancer Center) comparing the right (n=202) and left thoracic approach esophagectomy (n=235) found no signi cant difference in 5-year survival rate. [20] The Henan colleagues argued that the left approach as described in the Fudan trial might have been unrepresentative of a standard Sweet approach by experienced hands in high volume centers because the usual advantages in operation time, hospital stay and surgical complication are not apparent as compared to that in other Chinese studies. [18-21,25]Interestingly however, Henan colleagues not only demonstrated the usual advantages concerning surgical safety for the Sweet approach, the median number of lymph node retrieved by them with the left approach was no less than that with the right approach (median 21 (8-64) vs.26 (8-60), P=0.708).…”

“…[18-21,25]Interestingly however, Henan colleagues not only demonstrated the usual advantages concerning surgical safety for the Sweet approach, the median number of lymph node retrieved by them with the left approach was no less than that with the right approach (median 21 (8-64) vs.26 (8-60), P=0.708). [20] The discrepancy between these two studies seem to suggest that both a minimum complication and a complete lymphadenectomy are mandatory for the improvement of long term survival, and currently in China regarding both there is room for improvement.…”

Preemptive analgesia in the “non-tube no fasting” fast track program for resectable esophageal carcinoma

“…Surgical treatment of esophageal carcinoma has a history of 100 years, and the first esophagectomy was successfully completed by Torek in 1913 (1). As medical science has advanced and our understanding of esophageal carcinoma has improved, esophageal carcinoma surgery has developed from the initial left thoracic approach to the right thoracic approach (2) and to the current minimally invasive esophagectomy (MIE) (3), and the surgical methods continue to improve. Open esophagectomy involves extensive trauma, severe pain, and high complication and mortality rates.…”