Evolution in Surgical Management of Esophageal Cancer

Abstract

Esophageal resection remains the primary treatment for local regional esophageal cancer, although its role in superficial (T1A) cancers and squamous cell cancer is in evolution. Mortality associated with esophagectomy has historically been high but is improving with the current expectation of in-hospital mortality rates of 2-4% in high-volume centers. Most patients with regional cancers (T2-4 N0-3) are recommended for neoadjuvant therapy, which most commonly involves radiochemotherapy. Some centers have proposed treating with definitive chemoradiation and reserving surgery for patients who have persistent or recurrent disease. ‘Salvage resections' are possible but are associated with higher levels of perioperative morbidity and mortality, and treatment decisions should routinely be based on multidisciplinary discussion in the tumor board. Although open surgical resection (both transthoracic and transhiatal operations) remain the most common approach, minimally invasive or hybrid operations are being done in up to 30% of procedures internationally. There are some indications that minimally invasive esophagectomy may decrease the incidence of respiratory complications and decrease length of stay. At this point, oncologic outcomes appear equivalent between open and minimally invasive procedures. Recent reviews from high-volume esophagectomy centers demonstrate that elderly patients can selectively undergo esophagectomy with the expectation of increased complications but similar mortality and survival to younger patients. Multiple studies confirm that quality of life following esophagectomy can be equivalent to the general population when surgery is done in experienced centers. Patients requiring surgical treatment of esophageal cancer should be referred to high-volume centers, especially those with established care pathways or enhanced recovery programs to improve outcomes including morbidity, mortality, survival, and quality of life.

Quality Management and Key Performance Indicators in Oncologic Esophageal Surgery

“…On the process level, it has been postulated that standardized clinical pathways and enhanced recovery programs can improve the quality of treatment after esophagectomy [69]. Iannettoni et al [70] have shown that the KAIZEN method can be successfully employed in patients with esophageal resection due to the elimination of variability, standardization of treatment processes with improved results, decreased length of hospital stay, and reduced costs.…”

Nutrition in peri-operative esophageal cancer management

“…In the years following surgery, patients often experience problems affecting nutritional status, such as diarrhea, appetite loss, nausea, and vomiting [11]. Improvement in outcome may be achieved by appropriate risk assessment [6,12,13], pre-optimization [14], use of multimodality treatment [3], centralization of esophageal cancer surgery [15], use of minimally invasive esophagectomy techniques [16,17], and an enhanced recovery in esophagectomy pathway [16,[18][19][20][21][22][23][24][25][26]. In many of these new developments, nutrition has an essential role.…”

Postoperative fluid overload is a risk factor for adverse surgical outcome in patients undergoing esophagectomy for esophageal cancer: a retrospective study in 335 patients

“…Surgery for esophageal cancer has traditionally been associated with high postoperative morbidity and mortality and poor long-term survival, but results have improved dramatically over the last decade [1, 2]. Improvements in perioperative management and surgical technique have contributed to a reduced rate of surgical and medical complications, but the impact of each individual factor remains vague.…”