Abstract
Simple SummarySubtotal resection of the esophagus with resection of local lymph nodes is the oncological procedure of choice for advanced esophageal cancer. Reconstruction of the intestinal tract is predominantly performed with a gastric tube. Even in specialized centers, this surgical procedure is associated with a high complication but low mortality rate. Therefore, clinical research aims to develop peri- and intra-operative strategies to improve the patient related outcome.Transthoracic esophagectomy is currently the predominant curative treatment option for resectable esophageal adenocarcinoma. The majority of carcinomas present as locally advanced tumors requiring multimodal strategies with either neoadjuvant chemoradiotherapy or perioperative chemotherapy alone. Minimally invasive, including robotic, techniques are increasingly applied with a broad spectrum of technical variations existing for the oncological resection as well as gastric reconstruction. At the present, intrathoracic esophagogastrostomy is the preferred technique of reconstruction (Ivor Lewis esophagectomy). With standardized surgical procedures, a complete resection of the primary tumor can be achieved in almost 95% of patients. Even in expert centers, postoperative morbidity remains high, with an overall complication rate of 50–60%, whereas 30- and 90-day mortality are reported to be <2% and <6%, respectively. Due to the complexity of transthoracic esophagetomy and its associated morbidity, esophageal surgery is recommended to be performed in specialized centers with an appropriate caseload yet to be defined. In order to reduce postoperative morbidity, the selection of patients, preoperative rehabilitation and postoperative fast-track concepts are feasible strategies of perioperative management. Future directives aim to further centralize esophageal services, to individualize surgical treatment for high-risk patients and to implement intraoperative imaging modalities modifying the oncological extent of resection and facilitating surgical reconstruction.
Highlights
According to international and national guidelines, surgery is generally accepted as the mainstay of curative treatment for esophageal adenocarcinoma [1,2,3]
This review aims to summarize the present evidence on surgical strategies currently applied for esophageal adenocarcinoma, and to point towards unsolved questions associated with the surgical management of this tumor entity
More than 80% of patients with esophageal adenocarcinoma receive some kind of neoadjuvant treatment prior to esophagectomy, and at the present it is not clear whether chemoradiotherapy and/or chemotherapy alone should be considered as a potential risk factor for postoperative morbidity
Summary
According to international and national guidelines, surgery is generally accepted as the mainstay of curative treatment for esophageal adenocarcinoma [1,2,3]. More than 80% of patients with esophageal adenocarcinoma receive some kind of neoadjuvant treatment prior to esophagectomy, and at the present it is not clear whether chemoradiotherapy and/or chemotherapy alone should be considered as a potential risk factor for postoperative morbidity. In a recent meta-analysis summarizing data from 39 eligible studies, various patientrelated factors associated with major postoperative complication and mortality were identified [27] These included male sex, age > 70 years, American Society of Anesthesiologists (ASA) score > III, cardiac and renal comorbidities, diabetes and habitual alcohol usage. Invasive techniques (including hybrid procedures), and operations performed in high-volume centers were protective, whereas increasing age, comorbidities and histology of squamous cell carcinoma were independent predictors of mortality Using these simple variables, a set of sensitivity/specificity analyses defined low- and high-risk patients, which correlated with the observed postoperative mortality. Since a clear-cut score has not been established yet, the decision making in terms of esophagectomy is left to the surgeon’s personal experience and discussion with the patient at the preoperative evaluation
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