Supplement: The Minimally Invasive Thoracic Surgery SummitSection II: EsophagusResection for Esophageal Cancer: Strategies for Optimal Management
Section snippets
Methods
We reviewed our experience and the medical literature on the various factors that may have an impact on the outcomes after esophagectomy. These include patient selection, staging strategies, the surgical approach, extent of resection, and the role of multimodality therapy for the treatment of esophageal cancer. The medical literature was searched using United States National Library of Medicine service, PubMed, and the following key words were chosen: esophageal cancer, esophagectomy, risk
Staging
Proper patient selection includes accurate staging and risk assessment of the patient. Accurate staging is critical for selection of appropriate treatment strategy, enrollment in clinical trials, and in the evaluation of results [2]. The current modalities of staging include computed tomography (CT) scanning, positron emission tomography (PET) scanning, and endoscopic ultrasound (EUS) [3, 4, 5, 6, 7, 8]. In addition, minimally invasive staging (MIS) with laparoscopy in particular is practiced
Surgical Approaches
The various open approaches used for esophageal resection include transhiatal resection or transthoracic approaches such as Ivor Lewis esophagectomy, resection with a left thoracotomy or a left thoracoabdominal approach, and the “3-incision” McKeown-type esophagectomy [13, 14, 15, 16, 17, 18]. The choice of approach depends on various factors, including the location of the tumor, the preference of the surgeon, and the choice for esophageal reconstruction. Large single-institution series have
Minimally Invasive Esophagectomy
A main concern for recommendation of esophagectomy is the risk associated with the surgical procedure. In an effort to decrease the morbidity and mortality from this procedure, recent advances in MIS have allowed us to develop and refine the technique of minimally invasive esophagectomy (MIE) at the University of Pittsburgh. We have described the technique and our experience at the University of Pittsburgh in detail [22].
We reported our results of a series of 222 consecutive MIEs [22].
Neoadjuvant Chemotherapy
The potential benefits of neoadjuvant chemotherapy include earlier treatment of micrometastatic disease and downstaging of tumor with possible increase in curative resection. Neoadjuvant chemotherapy for locally advanced tumors is preferred at our institution. We recently reported the long-term results of a phase II trial of neoadjuvant therapy for the treatment of esophageal cancer at the University of Pittsburgh [23]. Patients received preoperative chemotherapy with cisplatin, 5-flurouracil,
Reducing the Surgical Risks
Several studies have now shown the association between the mortality rate for esophagectomy and hospital volume: the mortality rate is significantly lower in high-volume centers vs low-volume centers [37, 38]. Surgeon volume and specialty training also have an impact on the mortality rate. In a recent study by Dimick and coworkers [39], the mortality rate was significantly lower for thoracic surgeons compared with surgeons without specialty training. The difference in mortality rates between
Conclusions
Surgical resection is the primary curative modality in patients with resectable esophageal neoplasm. Strategies to optimize surgical outcomes include optimal patient selection, accurate staging, and stage-directed therapies that include a multimodality approach in localized advanced esophageal cancer. The type of surgical approach is typically based on surgeon preference, and in some centers such as ours, a minimally invasive approach is used. Other important factors are hospital and surgeon
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