This is a retrospective study conducted in a single center describing our experience in potentially curative esophagectomy and esophageal reconstruction for cancer over the last 10 years. Only few randomized trials have been published on this topic probably for several reasons: significant differences in esophageal cancer population, difficulty in standardization of the surgical technique, limited number of cases, few centers performing esophageal surgery. First of all the choice of the surgical approach is still debating.
Two major surgical strategies can be employed: en-block trans-thoracic resection or an extended resection with two or three field lymphoadenectomy. In alternative, in order to reduce the incidence of perioperative morbidity and mortality a trans-hiatal approach can be used. Several studies in fact demonstrated that the risks of respiratory complication, wound dehiscence, chylous leakage, and infection are higher after trans-thoracic esophagectomy[2–4] than trans-hiatal approach. Also the intensive care unit and the hospital length of stay are significantly longer after trans-thoracic approach.
On the other hand,[5, 6] trans-thoracic esophagectomy seems associated with a significant trend toward improved long term survival. We agree with this evidence and in our series most of the patients underwent trans-thoracic esophagectomy. We performed a trans-hiatal esophagectomy only in 3 cases due to the junctional location of the tumor.
Although minimally invasive techniques are gaining in popularity, until now large randomized trials are not yet available. We performed video-assisted thoracoscopic esophagectomy only in case of early stage cancer in patients with high cardio-respiratory risk, in order to reduce the post-operative morbidity. The stomach was the method of reconstruction employed in most of the patients. We preferred to prepare a narrow gastric tube without performing piloroplasty placed in the anatomical pre-vertebral position. The advantages a narrow gastric tube are that it can be pulled up easily to the neck without tension, its excellent elasticity and reduced mediastinal encumbrance. Extra-anatomical reconstructions (retro-sternal or subcutaneous) might offer the theoretical advantage that a recurrent tumor mass will not involve the new esophagus but this choice requires a longer tube preparation. The extent of lymphnode dissection required for patients with esophageal cancer is still controversial. There are surgeons that prefer three-field lymphadenectomy, which includes abdomen, chest and neck, and proponents of the two-field lymphadenectomy, which includes abdomen and chest only. One of the potential advantages of transthoracic approach is better exposure and improved mediastinal lymphnode dissection when compared to the trans-hiatal esophagectomy. On the other hand, we preferred a two-field lymphadenectomy and notwithstanding a cervical anastomosis was performed in all cases. Although a multi-institutional trial reported that of the 30% of patients undergoing three-field lymphadenectomy with cervical lymphnode metastaases 20% occurred in patients with lower esophageal cancer, survival data are conflicting; in addiction the alleged benefit of the three-field lymphadenectomy has not been confirmed in a prospective randomized trial. Furthermore, the associated morbidity is higher ranging between 35% to 45%[7]. Another controversial issue is the site of the anastomosis in the neck or in the chest. Although proponents of intra-thoracic anastomosis point out the reduced tension and a lower risk of anastomotic complication, we prefer to use cervical anastomosis since it allows larger proximal margin of resection and in case of leakage less risks of dangerous mediastinal infection. The technique of our cervical anastomosis has been already described[8]. We prefer to accomplish a complete mechanical anastomosis. In our series we did not record any anastomotic leakage or other early anastomotic complication. Some authors reported a higher incidence of anastomotic strictures after stapled anastomosis in patients with a small diameter of the esophagus[9]. In our series, only 3 patients (4,2%) developed a late stenosis successfully treated with endoscopic dilation. Because gastric emptying may be impaired after esophagectomy and esophageal reconstruction with stomach, the use of pyloroplasty may be employed. A meta-analysis by Urschel et al.[10] showed that routine pyloroplasty is unnecessary. We agree with them and in our series we never performed pyloroplasty and we did not observe impaired gastric emptying. Furthermore, pyloroplasty might increase the risk of duodeno-gastric biliary reflux for gastric tube placed in the anatomical pre-vertebral position[11].
At our institution, platinum based induction chemotherapy is preferred to chemo-radiotherapy in locally advanced tumors with the potential benefits of earlier treatment of micro-metastases and down-staging of tumor. Although randomized studies did not have shown a consistent benefit in term of survival[12–14] in our series 12 patients (%) presented down-staging of tumor and in 3 no residual tumor was histologically found. In this group, median survival was 38 months and 5 year survival was 44,8%. Comparison of survival between patients undergone induction chemotherapy and surgery versus surgery alone was not statistically different suggesting the efficacy of induction chemotherapy in terms of down-staging of tumor and survival. Moreover, although in the literature several studies reported an increased risk of surgical complications after induction chemotherapy[12, 13], this observation was not confirmed in our series. Early pathologic tumor stage (pT) with less degree of trans-mural invasion carried a significant survival advantage (Figure 3). probably also because the prevalence of nodal metasteses increase with increasing depth of tumor penetration into the esophageal wall[15]. In our study, we have found that N0 patients had significant improvement in long term survival. (Figure 4) with a 5-year survival of 87,7%.
